Presentation on theme: "Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Central Line Infections Avoidable? Preventable?"— Presentation transcript:
Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Central Line Infections Avoidable? Preventable?
Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro What is a CLC-RBSI? Can we avoid them? The IHI tools The UHW experience
Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro "When you can measure what you are speaking about, and express it in numbers, you know something about it." Lord Kelvin, Popular Lectures and Addresses, 1889
Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro HCAI Surveillance In Wales the Welsh Assembly Government asked for the development of a mandatory HCAI surveillance programme for Critical Care in 2005
Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro WCCIP established May 2006 Aim to introduce care bundles into Critical Care in Wales CVC care bundle VAP care bundle
Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro WHAIP / WCCIP collaboration Development of surveillance programme to underpin the improvement work. Agreed definitions together All critical care units in Wales engaged and conducting surveillance in advance of the scheme becoming mandatory
Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro What is a CVC infection? Definitions –CDC Nosocomial Infection National Surveillance Scheme (NINSS) –HELICS
Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro European surveillance scheme Allows benchmarking across Europe
CVC Surveillance Results Sep 07 – Dec 08 Patients in Wales in ICU with lines inserted between 01/09/07 – 31/12/08 Provisional Data from the National Mandatory HCAI surveillance programme, Wales - WHAIP team NPHS
Reducing HCAI Content Areas Improving leadership for quality Reducing healthcare associated infectionsReducing healthcare associated infections Improving critical care* Improving medicines management Reducing surgical complications* Improving general medical and surgical care Development Sites * Trusts Only
Reducing HCAI What can cause CVC 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.......
Reducing HCAI 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
Reducing HCAI 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
Reducing HCAI 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
Reducing HCAI 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
Reducing HCAI What else is a bundle? Methodology to spread the use of generally accepted science
Reducing HCAI What else is a bundle? Methodology to spread the use of generally accepted science Provide a “pressure” for teamwork
Reducing HCAI What else is a bundle? Methodology to spread the use of generally accepted science Provide a “pressure” for teamwork Simple, memorable checklist
Reducing HCAI What else is a bundle? Methodology to spread the use of generally accepted science Provide a “pressure” for teamwork Simple, memorable checklist Audit tool
Reducing HCAI 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
Reducing HCAI Bundles bridge the “Guideline Gap” Evidence Guidelines Practice Bundle
Reducing HCAI 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
Reducing HCAI Types of Care Bundles Ventilator Care Bundle Sepsis Care Bundle Central Line Care Bundle
Reducing HCAI 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
Reducing HCAI 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
Reducing HCAI 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 necessityYes No (To be documented in patients notes) 6. Ultra sound used for insertionYes No Central Line Care Bundle
Reducing HCAI Results Structure in place Process in place........... will result in the desired outcome
Reducing HCAI 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
Reducing HCAI 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
Reducing HCAI 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.
Reducing HCAI 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
Reducing HCAI Use the PDSA Cycle for : Testing or adapting an improvement change Implementing the change Spreading the change to the rest of your system
Reducing HCAI 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
Reducing HCAI Use a PDSA form to organize, standardize and document your tests!
Reducing HCAI Plan Clear objective State predictions Who, what, where, when? Describe data collection plan
Reducing HCAI 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
Reducing HCAI Study Complete the analysis of the data Analyse feedback or observations Compare data/feedback to predictions & summarise what was learned Suggestions
Reducing HCAI Act What will happen in the next PDSA cycle? Develop change further? Test? Implement?
Reducing HCAI 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
Reducing HCAI 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
Reducing HCAI AIM Change Concepts, Theories, Ideas Concept B Concept C Concept A Concept D Multiple PDSA Cycles Directed Toward a Single Aim
Reducing HCAI 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
Reducing HCAI References on Measurement and Improvement Brook, R. et. al. “Health System Reform and Quality.” Journal of the American Medical Association 276, no. 6 (1996): 476-480. 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): 135- 147.\ Associate in Process Improvement. The Improvement Handbook: Models, Methods and Tools for Improvement, Austin, TX, January 2005.