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Tamara Johnson RN Director Clinical Integration Ivera Medical Corporation.

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Presentation on theme: "Tamara Johnson RN Director Clinical Integration Ivera Medical Corporation."— Presentation transcript:

1 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) 2

3 CLABSI TIMELINE  2001 – Beginning of the term “Never Events” 3  2012 – Updated CLABSI Definitions from CDC  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  2013 – Updated CLABSI Definitions from CDC  2014 – Updated CLABSI Definitions from CDC

4 FROM OUR FRIENDS AT THE CDC… 4 1. )  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

5 A REMINDER ABOUT GREAT VESSELS 1  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 5 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 6

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

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

9 PROTECTING OUR PATIENTS…  Implementation of “Bundles” 9 7.)  Bundle 7 - 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

10 CLABSI BUNDLES  Central Line Insertion Practices (CLIP) ) sc_CLIPcurrent.pdf  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

11  Extraluminal vs Intraluminal  CLIP = happens one time on a patient  Maintenance = happens all day long by a lot of different people (#1) 11 CLIP VS MAINTENANCE 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  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 ✔ 12 9.) html CENTRAL LINE MAINTENANCE “GUIDELINES” #2

13 NEEDLELESS CONNECTOR DISINFECTION Java Vol 12, No 3,

14 “SCRUB THE HUB”  15 seconds 14

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) 15   #3

16 AND THE SURVEY SAYS… 16

17 17

18 CHALLENGES WITH CLABSIs  Many Ports of Entry into the bloodstream 18 #4

19 19 Culture from a patient’s needleless connector. – Wendy Kaler, MT, MPH, CIC CHALLENGES WITH CLABSI  Cannot See Microorganisms – blessing and curse #5

20 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 21

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 22

23 HOW A PORT PROTECTOR WORKS 23 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 24

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? 25

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 26

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 27

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 28

29 29 SIX SIGMA PROJECT – TX HOSPITAL 1. Open MAR 2. Scan Medication3. Prepare Medication 4. Open Alcohol Pad 5. Scrub Hub for 15 sec 6. Dry for 15 sec 7. Administer Medication = 66 sec per injection (Avg. time spent in 12hr shifts giving IV injections)

30 ADVANTAGES TO PORT PROTECTION Open MAR2. Scan Patient 3. Scan Medication 4. Prepare Medication 5. Remove Port Protector 6. Administer Medication 64 % reduction! 7. Replace with new port protector = 23.7 sec per injection

31 EVEN SIMPLE SOLUTIONS HAVE CHALLENGES  The “Silver Bullet Syndrome”  Hand Hygiene  Clean, Dry, Intact Dressings  Confusing Protocol  Forced Compliance vs. Non-Forced Compliance 31

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

33 MAIN CHALLENGE? 33 #10

34 Thank You! Questions? 34

35 CHALLENGE ACCEPTED  Product Location  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 35

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 37

38 38 The single biggest problem with COMMUNICATION 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 39

40 WEEKLY UNIT REPORTING 40

41 CELEBRATE SUCCESSES 41

42 I DON’T HAVE TIME! 42

43 ORGANIZATIONS WHERE ONE BREACH IN PROCESS CAN IMPACT LIVES… 43

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. 44

45 SHEA/IDSA PRACTICE RECOMMENDATIONS INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY, VOL. 35, NO. 7 (JULY 2014) PP 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 45

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%) 46

47 CONCLUSION  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 47

48 ANY QUESTIONS? 48


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