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Implementing a Better Bundle in the Adult Population to Attain Zero Central Line Associated Blood Stream Infections: A Prospective Surveillance Timothy.

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Presentation on theme: "Implementing a Better Bundle in the Adult Population to Attain Zero Central Line Associated Blood Stream Infections: A Prospective Surveillance Timothy."— Presentation transcript:

1 Implementing a Better Bundle in the Adult Population to Attain Zero Central Line Associated Blood Stream Infections: A Prospective Surveillance Timothy Royer, BSN, CRNI, Nurse Manager / IV Team – Retired 2009 VA Puget Sound Health Care System, Seattle, Washington

2 Timothy Royer, RN, BNS, CRNI Financial Disclosures Nurse Consultant for: –Genentech – Cathflo Nurse Trainer –Medegen – Clinical Practice Consultant –Ethicon – Speaker’s Bureau The studies presented herein were completed independently, without financial support, input, or influence from any manufacturer or commercial entity.

3 Timothy Royer, RN, BNS, CRNI Objectives of this Presentation 1. Discuss 4 components of the central line bundle 2. Discuss strategies to implement the central line bundle

4 Timothy Royer, RN, BNS, CRNI Topics Covered 1. National Patient Safety Goals (NPSG)s 2. IHI Guidelines/Recommendations 3. Components of the central line bundle 4. Additional components to add to the central line bundle 5. Implementing the central line bundle 6. Strategies for implementing the central line bundle 7. Measuring outcomes of the central line bundle

5 Timothy Royer, RN, BNS, CRNI NPSG VII. Goal 7 – Reduce the risk of health care – associated infections. –A. Meeting Hand Hygiene Guidelines (NPSG ) –B. Not applicable to hospitals –C. Preventing Multidrug-Resistant Organism Infections (NPSG ) –D. Preventing Central Line–Associated Blood Stream Infections (NPSG ) –E. Preventing Surgical Site Infections (NPSG )

6 Timothy Royer, RN, BNS, CRNI IHI The central line bundle has five key components: –Hand hygiene –Maximal barrier precautions –Chlorhexidine skin antisepsis –Optimal catheter site selection, with avoidance of using the femoral vein for central venous access in adult patients –Daily review of line necessity, with prompt removal of unnecessary lines

7 Timothy Royer, RN, BNS, CRNI Standards of Practice Besides looking at the NPSG, IHI, CDC Guidelines, and the Draft of the new CDC “Guidelines for the Prevention of Intravascular Catheter- Related Infections” we need to be guided in our practice with the “Infusion Nursing Standards of Practice”. Your Standards of Practice should look well used too. Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs. 2006;29(1S)

8 Timothy Royer, RN, BNS, CRNI What Do We Do?? Protect the patient from the central venous catheter. –Extraluminal causes for infection –Intraluminal causes for infection How do we get there? –Device selection –Care and Maintenance –Staff and patient education –Specialized Teams (IV Teams, Vascular Access Teams) What does it really boil down to? Finding evidence and using critical thinking to make the right choices

9 Timothy Royer, RN, BNS, CRNI Do we ever say, “That’s the way we have always done it”? Just Asking

10 Timothy Royer, RN, BNS, CRNI Where Evidence Points Additions with Overwhelming Evidence Logical Additions with Evidence Still Being Gathered Maximum sterile precautionsSwabable connector surfaces CHG PrepCHG bath in the ICUs Special trained teams – IV TeamsSutureless manufactured securement devices Hand HygieneStandardized Catheter insertion cart with checklist Scrubbing hub of catheter or connectorClear housing on needleless connectors Education of nurses and physiciansMore PICCs in ICU Prompt removal of unnecessary linesCHG eluting disk – near overwhelming evidence for routine use Impregnated gel dressing – little evidence thus far Saline flushing and locking; elimination of heparin Decloting catheters

11 Timothy Royer, RN, BNS, CRNI Maximum Barrier Precautions For the operator placing the central line and for those assisting in the procedure, maximal barrier precautions means strict compliance with hand hygiene and wearing a cap, mask, sterile gown, and sterile gloves. Include maximal barrier precautions as part of your checklist for central line placement. Means covering the patient from head to toe with a sterile drape, with a small opening for the site of insertion. Using a checklist and empowering nurses to stop the procedure if sterile technique is broken.

12 Timothy Royer, RN, BNS, CRNI Removal of Unnecessary Lines Include daily review of line necessity as part of your multidisciplinary rounds. State the line day during rounds to remind all as to how long the line has been in, e.g., “Today is line day 6.” Include assessment for removal of central lines as part of your daily goal sheets. Record time and date of line placement for record- keeping purposes and evaluation by staff to aid in decision making. Define an appropriate timeframe for regular review of necessity, such as weekly, when central lines are placed for long-term use (e.g., chemotherapy, extended antibiotic administration, etc.). Daily review was designed for the intensive care population and may not be appropriate when long-term use over weeks or months is planned. No, it is not OK to say “Just in Case…”

13 Timothy Royer, RN, BNS, CRNI Evidence on Removal of Unnecessary Lines Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter- related bloodstream infections in the ICU. N Engl J Med 2006;355: Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32:

14 Timothy Royer, RN, BNS, CRNI Background for the Studies It is the goal of every infusion nurse and facility to have a zero Central Line Associated Blood Stream Infection (CLA-BSI) rate to prevent: –Morbidity –Mortality –Excess cost of care The central line bundle is a good start for insertion, we were looking for improvement and added additional items to come up with a Central Line Care and Maintenance Bundle (CLC&M Bundle)

15 Timothy Royer, RN, BNS, CRNI Building a Better Care Bundle What We Did June Change to swabable positive displacement valve January 2005 – Maximal sterile barriers & CHG prep July Chlorhexidine Gluconate (CHG) impregnated disk, increase use of PICCs in place of centrally inserted central catheters (CICVC), and a vigorous care and maintenance education program January 2007 – Started clear version of the same valve, as a cue, coupled with continuous Medical Center ”Scrub the Hub and Flushing with 20mls. of normal saline” campaign.

16 Timothy Royer, RN, BNS, CRNI Infection Rate Run Chart

17 Timothy Royer, RN, BNS, CRNI Rationale Behind the Additions to the CLC&M Bundle

18 Timothy Royer, RN, BNS, CRNI Evidence & Logic for Additions Evidence and critical thinking that was used reduce Central line Associated Blood Stream Infections (CLABSI) (some newer references also cited):  Specialized trained staff for central venous catheters IV Teams  Swabable needleless connectors allow for a greater reduction of bacteria colony counts on devices  Clots form a tighter matrix when precipitates are present in the lumen in the catheter  Central venous catheters with clots are at higher risk for infection  Positive displacement valves prevent blood from backing up the catheter on syringe removal

19 Timothy Royer, RN, BNS, CRNI  Prevention and/or early decloting of catheters reduces the risk of infection  Switching to saline locks from heparin  Using manufactured securement devices reduces infection risk  Education on CVC care improves patient outcomes including reducing CLA-BSI  Peripherally Inserted Central Catheters (PICC) have a lower infection risk  Chlorhexidine (CHG) eluting disk or dressings provide an environment to keep colony counts low around insertion site  Clear housing for needleless connectors Evidence & Logic for Additions continued

20 Timothy Royer, RN, BNS, CRNI IV Teams / PICC Teams / Vascular Access Teams Not PICC Stick and Run teams or teams that perform venipunture well. Coordinate with Infectious Disease (Infection Preventionists) and Physician Directors of Departments. Very active participants in the Care and Maintenance of CVCs –Educate nurses on best practices –Using vigilance to ensure best nursing care and practices are sustained –Provide additional training and education when new practices or products are implemented They should be active within committees –Infectious Disease –Disposable Equipment Committee (DEC) –Nurse Practice Committee (NPC) –Facility Education Department –Equipment Committee –Pharmacy and Therapeutic Committee

21 Timothy Royer, RN, BNS, CRNI Bring in new vascular access products –The Steps Review new product Self testing the devices –Will it work? –Does it work like they say it does? –Where is the evidence? »Manufacturer generated? »What level of research? –Does it make sense? –Talk to your colleagues in different facilities –Talk with the manufacturers’ engineers –Talk with your own facility medical equipment engineers IV Teams / PICC Teams / Vascular Access Teams

22 Timothy Royer, RN, BNS, CRNI Clinical Evaluation –Involve all members of the Team »Specialized Teams »Unit Managers and staff »Disposable Equipment Committee Make the right choice for the patient. Present to the NPC and DEC Now the real hard work begins IV Teams / PICC Teams / Vascular Access Teams

23 Timothy Royer, RN, BNS, CRNI  Staff education  Pre-educate the whole hospital on the new product coming in.  Be part of the education on the product.  Competencies  Gathering Data with the CICs  Initiating practice change  Research – whether actual or reading and implementing change. IV Teams / PICC Teams / Vascular Access Teams

24 Timothy Royer, RN, BNS, CRNI Draft of CDC Guidelines References for having “IV Teams” Nehme AE. Nutritional support of the hospitalized patient. The team concept. JAMA 1980;243: Soifer NE, Borzak S, Edlin BR and Weinstein RA. Prevention of peripheral venous catheter complications with an intravenous therapy team: a randomized controlled trial. Arch Intern Med 1998;158:473-7 Tomford JW, Hershey CO, McLaren CE, Porter DK and Cohen DI. Intravenous therapy team and peripheral venous catheter-associated complications. A prospective controlled study. Arch Intern Med 1984;144: Scalley RD, Van CS and Cochran RS. The impact of an i.v. team on the occurrence of intravenous-related phlebitis. A 30-month study. J Intraven Nurs 1992;15:100-9 Palefski SS, Stoddard GJ. The infusion nurse and patient complication rates of peripheral- short catheters. A prospective evaluation. J Intraven Nurs 2001;24: Miller JM, Goetz AM, Squier C and Muder RR. Reduction in nosocomial intravenous device- related bacteremias after institution of an intravenous therapy team. J Intraven Nurs 1996;19:103-6 Hunter MR. Development of a Vascular Access Team in an acute care setting. J Infus Nurs 2003;26:86-91 Hawes ML. A proactive approach to combating venous depletion in the hospital setting. J Infus Nurs 2007;30:33-44 Brunelle D. Impact of a dedicated infusion therapy team on the reduction of catheter- related nosocomial infections. J Infus Nurs 2003;26:362-6 Bosma TL, Jewesson PJ. An infusion program resource nurse consult service: our experience in a major Canadian teaching hospital. J Infus Nurs 2002;25:310-5 Pierce CA, Baker JJ. A nursing process model: quantifying infusion therapy resource consumption. J Infus Nurs 2004;27:232-44

25 Timothy Royer, RN, BNS, CRNI Swabable Needleless Connectors Hadaway L, Richardson D. Needleless connectors? A primer on terminology. Journal of Infusion Nursing. 2010, Vol. 33:1 –The configuration of the external connection surface can have a direct impact on the outcome with the device. –The surface design is thought to be one factor in the controversy over the infection risk associated with each device. Needleless connectors with smooth contours, no valleys, no crevices, and no hidden pockets have the easiest surfaces to disinfect. When we made the switch in June 2003, little evidence was out there but it made good sense. Hadaway L, Richardson D. Needleless connectors: A primer on terminology. Journal of Infusion Nursing. 2010, Vol. 33:1. This applies to all vascular access device not just central

26 Timothy Royer, RN, BNS, CRNI Precipitates and Clots Hardy –Suggests that a significant portion of clot occlusions seen in practice may be caused by many factors, including drug precipitates. –States a more tense fibrin matrix forms around the drug precipitates which leads to the formation of occlusions. A clear needleless connector allows nurses to see if appropriate flushing was performed and if not, to continue flushing or change valve for improved outcomes The photo illustrates an improperly flushed valve removed from a patient Investigation on clear valves removed from patients Hardy G, Ball P. Clogbusting: time for a concerted approach to catheter occlusions? Current Opinion in Clinical Nutrition and Metabolic Care. 2005, 8:277–283

27 Timothy Royer, RN, BNS, CRNI Clots and Infection We have known about the association of clots and infection for a long time: –Timsit J, Farkas J, et al. Central vein catheter-related thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis. Chest 1998; 114; –Raad et al. The relationship between the thrombotic and infectious complications of CVC. JAMA –Stillman et al. Etiology of Catheter-associated sepsis: correlation with thrombogenicity. Arch Surg 1977

28 Timothy Royer, RN, BNS, CRNI Saline Instead of Heparin Evidence shows that heparin stimulates biofilm formation. –Shanks, Robert M. Q. et al Heparin Stimulates Staphylococcus aureus Biofilm Formation. Infection and Immunity. August 2005 p doe: /1AL –Costello JM, et. al. Systematic Intervention to Reduce Central Line–Associated Bloodstream Infection Rates in a Pediatric Cardiac Intensive Care Unit. Pediatrics. Vol. 121 No. 5 May 2008, pp

29 Timothy Royer, RN, BNS, CRNI Just Asking Research has demonstrated a correlation between catheter intraluminal biofilm formation and catheter- related bloodstream infection. –Andes D, et al. Development and Characterization of an In Vivo Central Venous Catheter Candida albicans Biofilm Model. Infection and Immunity, October 2004, p , Vol. 72, No. 10. “Recent estimates suggest that the majority of hospital- acquired infections are biofilm associated.” –Donlan, R. M Biofilm formation: a clinically relevant microbiological process. Clin. Infect. Dis. 33: –Licking, E Getting a grip on bacterial slime. Business Week, 13 September 1999, p –Potera, C Forging a link between biofilms and disease. Science 283: So, why are we using Heparin that stimulates Biofilm formation that is associated with Blood stream infections? Saline Instead of Heparin

30 Timothy Royer, RN, BNS, CRNI Prevention of clots Positive displacement valves decrease the risk of occlusion: –Jacobs BR, et al. Central venous catheter occlusions: A prospective, controlled trial examining the impact of a positive-pressure valve device. J. of Parenteral and Enteral Nutrition. 2004; 28: –Rummel M, Donnelly P, Fortenbaugh C. Clinical evaluation of a positive pressure device to prevent central venous catheter occlusion: Results of a pilot study. Clinical Journal of Oncology Nursing. 2001, 5, (6), –Feehery, Patricia A. RN, BS, CRNI, et al. Flushing 101, Journal of Vascular Devices, Summer 2003.

31 Timothy Royer, RN, BNS, CRNI Proactive Approach to Occlusion Because Evidence shows that clots are associated with infection: –Prevent clotting of catheters Proper flushing –Draft of the Guidelines for the Prevention of Intravascular Catheter-Related Infections: Exterior Housing of needleless connectors “inadequate flushing of the device due to poor visualization of the fluid flow pathway in opaque devices”. –INS Standard 35: INS Standard 35: Injection and Access Caps: “If the integrity of the injection or access cap is compromised or if residual blood remains within the cap, it should be replaced immediately and consideration should be given to changing the catheter and administration set.” Care and maintenance and proper tip placement –CVC with tips in a proximal position were 16 times more likely to have thrombosis than those in a distal position. –Cadman et al. To clot or not to clot? That is the question in central venous catheters. Clinical Radiology, 59;4: April 2004

32 Timothy Royer, RN, BNS, CRNI –Quick resolution of occluded catheter *Declot early with any signs of sluggish or non- aspirating CVCs –No tying or taping off of occluded lines Proactive Approach to Occlusion * Deitcher SR, Fesen MR, Kiproff PM, et al, for the Cardiovascular Thrombolytic to Open Occluded Lines-2 Investigators. Safety and efficacy of alteplase for restoring function in occluded central venous catheters: results of the Cardiovascular Thrombolytic to Open Occluded Lines trial. J Clin Oncol. 2002;20: Blaney M, Shen V, Kerner JA, for the CAPS Investigators. Alteplase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label, single-arm study (the Cathflo Activase Pediatric Study). J Vasc Interv Radiol. 2006;17: We are not taping off lumens with occlusions, are we? Just Asking

33 Timothy Royer, RN, BNS, CRNI Non-suture CVC Securement Citation used in the draft of the new CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections - Catheter securement devices. Lines –“Sutureless securement devices avoid disruption around the catheter entry site and may decrease the degree of bacterial colonization.” Yamamoto AJ, Solomon JA, Soulen MC, et al. Sutureless securement device reduces complications of peripherally inserted central venous catheters. J Vasc Interv Radiol 2002;13:77-81 INS Standards of Practice: Standard 43. Catheter Stabilization. –“Whenever feasible using a manufactured catheter stabilization device is preferred.” Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs. 2006;29(1S): S44.

34 Timothy Royer, RN, BNS, CRNI Staff Education on CVC Care Reducing CLA-BSIs with staff education –Costello study (2008) Interventions involving staff education, increased awareness, and practice changes led to decreased rates –Garcia study (2007) An extensive education program led to better adherence to proper infection control practices –Safdar study (2008) “The implementation of educational interventions may reduce HCAI considerably” Costello JM, et. al. Systematic Intervention to Reduce Central Line–Associated Bloodstream Infection Rates in a Pediatric Cardiac Intensive Care Unit. Pediatrics, Vol. 121 No. 5 May 2008, pp Garcia R, Jendresky L. A study of the effects on bacteremia and sharps injury rates after introduction of an advanced luer activated device (LAD) for intravascular access in a large hospital setting. American Journal of Infection Control, June 2007, Vol 35, Issue 5 E75. Safdar N, Abad C. Educational interventions for prevention of healthcare-associated infection: a systematic review. Crit Care Med (3):

35 Timothy Royer, RN, BNS, CRNI PICCs in ICUs have a Lower Infection Rate As noted in this facility’s Run Chart.

36 Timothy Royer, RN, BNS, CRNI Other Hospital (Med/Surg ICU) Data * Poster Presentation “Early Use of PICCs is Associated with Decreased Catheter-Related Blood Stream Infections” *Study from the Mayo Clinic Poster Presented at the 32nd Critical Care Congress of the Society of Critical Care Medicine as a Poster Abstract. Patel, B: 2003

37 Timothy Royer, RN, BNS, CRNI Chlorhexidine (CHG eluting disk) Why are we worried about extraluminally? –Most noncuffed CVCs BSIs were extraluminally acquired and derived from cutaneous microflora. Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Intensive Care Med Jan;30(1): More evidence that supports: –Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Intensive Care Med Jan;30(1): –Levy I, et al. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study. Pediatr Infect Dis J Aug:24(8);676-9.

38 Timothy Royer, RN, BNS, CRNI More Evidence on CHG disk –Chambers ST, et al. Reduction of exit-site infections of tunneled intravascular catheters among neutropenic patients by sustained- release chlorhexidine dressings: results from a prospective randomized controlled rial. Hosp. Infect : –Garland JS, e al. Local reactions to a chlorhexidine gluconate- impregnated antimicrobial dressing in very low birth weight infants. Pediarics. Jun;107(6): –Roberts B, Cheung D. Biopatch-a new concept in antimicrobial dressings for invasive device. Aust Crit Care Mar;11(1): –Fauerbach LL, et al. Continuing evolution of multidisciplinary approach to prevention of central line-associated bacteremias. AJIC. May 2004;(32)3. –Maki DG, et al. Prospective, randomized, investigator-masked trial of a novel chlorhexidine-impregnated disk on central venous and arterial catheters. Infect Cont Hosp Epidemiol Feb;21(2):96.

39 Timothy Royer, RN, BNS, CRNI Recently Published CHG Impregnated Sponges Clinical Evidence Timsit, J, Schwebel C, Bouadma L, et al. Chlorhexidine- Impregnated Sponges and Less Frequent Dressing Changes for Prevention of Catheter-Related Infections in Critically Ill Adults: A Randomized Controlled Trial. JAMA. 2009; 301(12): (doi: /jama Conclusions: In this study use of Chlorhexidine-Impregnated Sponges decreased the rates of catheter-related blood stream infection by 76 %.

40 Timothy Royer, RN, BNS, CRNI Dressings with CHG Gel Pads Evidence is very limited right now. Below are Posters presented at the Association for Vascular Access Conference 2009 in Las Vegas, NV. –Effect of Tegaderm Chlorhexidine Gluconate (CHG) Gel Dressing on Adult Central Venous Line Related Primary Bloodstream infections. Mary E. Reilly, RN, BSN. Decreased CLABSI from 2.1 to 0.7. –Chlorhexidine Gluconate (CHG) at Central Line Insertion Sites: Disc vs. Gel Pad Tegaderm. Pat Catudal, RN and Susanne Meninger, RN. Rates stayed the same, but “ease of use” was factor in selecting this product. –USE OF AN ANTIMICROBIAL IV DRESSING WITH A MAINTENANCE BUNDLE. Sally Valdez, RN, BSN and Barbara Calabrese, RN. Rates reduced from 1.4 to zero with switching to the gel pad dressing and more diligent adherence to their maintenance bundle.

41 Timothy Royer, RN, BNS, CRNI Needleless Connectors with Clear Housings

42 Timothy Royer, RN, BNS, CRNI Connectors with Clear Housing *INS Standard 35: INS Standard 35: Injection and Access Caps: “If the integrity of the injection or access cap is compromised or if residual blood remains within the cap, it should be replaced immediately and consideration should be given to changing the catheter and administration set.” **Using this Standard; a needleless connector with opaque housing does not allow the nurse to see if appropriate flushing was performed and if not to continue flushing or change the valve. *Infusion Nurses Society. Infusion Nursing Standards of Practice. J Infus Nurs. 2006;29(1S): S35. ** Hadaway L, Richardson D. Needleless connectors? A primer on terminology. Journal of Infusion Nursing. 2010, Vol. 33:1. Just Asking Why are we using opague housings?

43 Timothy Royer, RN, BNS, CRNI Draft CDC Guidelines Exterior Housing Potential explanations for outbreaks associated with these devices include difficulty encountered in adequate disinfection of the surface of the connector due to physical characteristics of the plastic housing diaphragm interface, fluid flow properties (laminar vs. turbulent), internal surface area, potential fluid dead space, inadequate flushing of the device due to poor visualization of the fluid flow pathway in opaque devices, and the presence of internal corrugations that could harbor organisms, particularly if the catheters are used to access blood

44 Clearly Beyond the Central Line Bundle A Five-Fold Decrease of Intravascular Central Line Associated Bloodstream Infections (CLABSI) in the six months. Reduction to zero CLABSI and sustained since. (July 2009)

45 Timothy Royer, RN, BNS, CRNI Research presented at the 2007 VHA MRSA Prevention Forum Showing the impact of clear needleless connectors in the first six months. One CLABSI in January 2007 in MICU

46 Timothy Royer, RN, BNS, CRNI Objective Intravascular needleless connectors can be a potential source of bloodstream contamination and infection To reduce contamination and bloodstream infections in the MICU and CCU: –Conduct staff education regarding potential sources of bloodstream infection –Implement clear valves which can be visually inspected to ensure proper flushing was performed and if residual remains, replace.

47 Timothy Royer, RN, BNS, CRNI Significant Results Central Line Associated Bloodstream Infections decreased five-fold from 7.4/1000 line days to 1.5/1000 line days (p<0.05) Blood Culture Contamination decreased 60% from 4.39/1000 line days to 1.77/1000 line days Cost savings avoidance of over $241,000 –Savings of $116,000 attributed to decrease in CLABSI –Savings of $125,000 attributed to decrease in contaminated blood cultures

48 Timothy Royer, RN, BNS, CRNI Summary After blood draws, blood residue not flushed from the valve may serve as a growth media for microbes Most valves are opaque and blood residue cannot be visualized Changing to a clear valve shows residue Efficacious flushing techniques and replacing valves if visible residue remains resulted in a five-fold decrease in Intravascular Catheter Associated Bloodstream Infections

49 Timothy Royer, RN, BNS, CRNI Changes Implemented to Reach Goal of Zero Replace standard opaque valves with clear valves that can be flushed clear Educate staff on the importance of disinfecting valves before every access, otherwise contamination on the access port may be infused into the patient Educate staff on the reason for practicing proper flushing techniques and for changing valves if visible residue remains, to remove growth media for microbes

50 Timothy Royer, RN, BNS, CRNI Valves may become contaminated with infusion residue or transient blood. CLEAR VALVES provide macroscopic inspection of residue. At our facility we reduced residue with 20-ml of flush solution.

51 Timothy Royer, RN, BNS, CRNI Risky residue should be revealed, not hidden! Clear valves can be visually inspected to ensure proper flushing techniques are practiced

52 Timothy Royer, RN, BNS, CRNI Goals for the 6 year Prospective Study Decrease Contaminated Blood Cultures Decrease CLABSI Rates Decrease Patient Care Costs Measures Defined Blood Culture Contamination rates per 1000 line days Defined CLABSI rates per 1000 line days using standard surveillance Calculated cost savings/avoidance

53 Timothy Royer, RN, BNS, CRNI Method Prospective surveillance and enhanced central line care in the whole medical center through a dedicated IV/PICC Team for the past 6 years. Prospective BSI surveillance and case finding were the responsibility of the IV Team and the infection control team. Infection rates tracked every 6 months using the NNIS and now the NHSN definitions. Data were tracked from January 2003 through July 2009

54 Timothy Royer, RN, BNS, CRNI Part of the Care and Maintenance Education Program

55 Timothy Royer, RN, BNS, CRNI Clear Valve Enhancement January 2007 With the switch to clear version of the same valve. –Realized a thorough flush involved 20mls. of Normal Saline (NS) To clear precipitates To clear blood –Better yet if valve has visible signs – Change the valve –Clear valve serves as a visual cue reminding nurses to complete best practices – priming, swabbing, and flushing

56 Timothy Royer, RN, BNS, CRNI Clear Valve Education Enhancement

57 Timothy Royer, RN, BNS, CRNI Results Over 13,000 of in-patient central line days per year –Includes CICVCs and PICCs –Rates were calculated for the whole Medical Center including Intensive Care Units (ICUs) Medical Surgical Units Spinal Cord Injury Unit Transitional Care Unit Using CHG disk along with a continuous vigorous education on the care of central lines produced a CLA-BSI rate from 1.92 to 0.63 Increasing the use of PICCs in place of CICVCs, especially in the ICUs, decreased infection rates. zeroImpressive continued drop to zero CLA-BSI rate was noted with the implementation of the use of clear positive displacement valves as a cue to clean, flush, or change the valve. P value <0.05 As of July, 2009 – 536 days with zero CLA-BSIs Cost savings of over $241,000 in the first six months for a five-fold decrease in CLA-BSI in the ICUs alone and 60% reduction in contaminated blood cultures (savings of $125,000 in contaminated cultures and $116,000 in bloodstream infections) as calculated, July 2007, VA Puget Sound Health Care System

58 Timothy Royer, RN, BNS, CRNI Infection Rate Run Chart

59 Timothy Royer, RN, BNS, CRNI Conclusions Decreases in CLA-BSI occurred with the use of: –Maximal Sterile Barriers & CHG prep –Increased use of PICCs in the ICU –CHG impregnated disk –Education program on catheter and hub/valve care –Dedicated IV/PICC Team –Swabable, positive displacement valve

60 Timothy Royer, RN, BNS, CRNI Conclusions All the reductions in CLA-BSIs are significant clinically However –A clinically and statistically significant drop in CLA-BSIs occurred and were sustained P>0.05 with: With clear positive displacement valves and a campaign reinforced with the clear valve visual cue to scrub the hub and flush the catheter or change the valve. CHG eluting disk.

61 Timothy Royer, RN, BNS, CRNI Implications for Practice in the Adult Population Protecting extraluminally with long acting CHG Blood and debris are growth media for bacteria –Care of catheters that include: Flush with 20mls of NS to clear the catheter Flush or change the valve if blood, precipitate or debris is visible, a clear valve makes this practice possible Coupled with a vigorous cued staff education program Are associated with reduced infections rates

62 Timothy Royer, RN, BNS, CRNI Are you Using Evidence and Critical Thinking? Just Asking

63 Timothy Royer, RN, BNS, CRNI Thank you. Questions?

64 Timothy Royer, RN, BNS, CRNI Remember not to lose Focus on the Whole Patient.


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