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Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Central Line Infections Avoidable? Preventable?

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

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

2 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

3 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

4 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

5 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

6 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

7 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

8 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro European surveillance scheme Allows benchmarking across Europe

9 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro

10 CVC surveillance introduced into mandatory HCAI surveillance programme in Wales September 2007 VAP surveillance added September 2008

11 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro Data collected on each patient with a CVC placed on ICU or in-situ on arrival in ICU

12 Cardiff and Vale NHS Trust Ymddiriedolaeth GIG Caerdydd a’r Fro

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14 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

15 Reducing HCAI April 2008 – April 2010

16 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

17 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

18 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

19 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

20 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

21 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

22 Reducing HCAI What else is a bundle? Methodology to spread the use of generally accepted science

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

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

25 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

26 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

27 Reducing HCAI Bundles bridge the “Guideline Gap” Evidence Guidelines Practice Bundle

28 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

29 Reducing HCAI Types of Care Bundles Ventilator Care Bundle Sepsis Care Bundle Central Line Care Bundle

30 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

31 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

32 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

33 Reducing HCAI Results Structure in place Process in place will result in the desired outcome

34 Reducing HCAI Structure Staff Equipment Documentation

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

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

37 Reducing HCAI S + P = O

38 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

39 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

40 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.

41 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

42 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

43 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

44 Reducing HCAI Use a PDSA form to organize, standardize and document your tests!

45 Reducing HCAI Plan Clear objective State predictions Who, what, where, when? Describe data collection plan

46 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

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

48 Reducing HCAI Act What will happen in the next PDSA cycle? Develop change further? Test? Implement?

49 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

50 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

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

52 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

53 Reducing HCAI UHW experience

54 Reducing HCAI Structure and Process Compliance with CLC Bundle

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

56 Reducing HCAI Outcome Zero CLC infections

57 Reducing HCAI No agreed definition HELICS agreed National surveillance in Wales

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

59 Reducing HCAI Future challenges Spread

60 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): 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.

61 Reducing HCAI


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