1. Vanderbilt Infection Control & Prevention Central Line Associated Bloodstream Infections Tennessee Center for Patient Safety Vicki Brinsko RN, CIC

2. Goal: Preventing CLABSI Using the Central Line Bundle Hand Hygiene Remove Unnecessary Lines Use of Maximal Barrier Precautions Chlorhexidine for Skin Antisepsis Avoid femoral lines Report CLABSI rates to the units Celebrate success Vanderbilt Infection Control & Prevention

3. Engage Partner with Infection Control, ID experts Increase awareness about morbidity and mortality associated with CLABSI Make harm visible Tell stories Post # infections Estimates of opportunity to improve Vanderbilt Infection Control & Prevention

4. Thank You Notes to NICU Staff Thank You From Baby Boy Jones I have gone 136 days without a bloodstream infection. Keep up the good work! My Mom left some “kisses” for you! XOXOX Vanderbilt Infection Control & Prevention

5. Form the Dream Team Heterogeneous in make up; homogeneous in mind set All stakeholders must be included All RN teams fail because MDs insert lines Find a high profile champion Get a process owner Vanderbilt Infection Control & Prevention

6. TEAM FORMATION ICU Director ICU Nurse Manager Infection Control Practitioners Chief Hospital Epidemiologist Attendings & Residents Nursing Staff (ICU) QA/Quality Staff QI experts Frontline Staff Infectious Disease experts Leaders Vanderbilt Infection Control & Prevention National Quality Scholars

7. Educate Educate staff and senior leaders about CDC guidelines Develop a resource notebook Develop policies and procedures CDC guidelines and Fact Sheet Power point slides for In-services Consider a quiz to evaluate provider knowledge Can use on-line training Vanderbilt Infection Control & Prevention

8. http://www.mc.vanderbilt.edu/root/vumc.php?site=micututorial

9. Evaluate Outcome measure: CLABSI rate Rate, # infections, weeks/months since last infection Process measures % checklists completed % violations noted # lines removed Celebrate success Vanderbilt Infection Control & Prevention

10. Share the Data Vanderbilt Infection Control & Prevention BSI Bundle

11. The Check List Adapt to your own institution Must be filled out for each line insertion Include 5 BSI bundle elements Simpler is better Can always add elements as you become better at capturing data Vanderbilt Infection Control & Prevention

12. Execute Hand Hygiene Remove Unnecessary Lines Use of Maximal Barrier Precautions Chlorhexidine for Skin Antisepsis Avoid femoral lines Vanderbilt Infection Control & Prevention

13. Hand Hygiene Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement, including hand hygiene, are executed for each line placement. Include hand hygiene as part of your checklist for central line placement. Keep soap/alcohol-based hand hygiene dispensers prominently placed and make universal precautions equipment, such as gloves, only available near hand sanitation equipment. Post signs at the entry and exits to the patient room as reminders. Initiate a campaign using posters including photos of celebrated hospital doctors/employees recommending hand hygiene. Create an environment where reminding each other about hand hygiene is encouraged. Vanderbilt Infection Control & Prevention

14. Posters of Prominent MDs

15. Maximum Barriers Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement. Include maximal barrier precautions as part of your checklist for central line placement. Vanderbilt Infection Control & Prevention

16. Insertion Kits or CL Carts Keep equipment stocked in a cart for central line placement to avoid the difficulty of finding necessary equipment to institute maximal barrier precautions. Some companies offer CL insertion kits with maximum barriers included Value in keeping as many parts together as possible May Need to Order CHG and/or Kits

17. CHG Skin Asepsis Vanderbilt Infection Control & Prevention Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement. Include chlorhexidine antisepsis as part of your checklist for central line placement. Include chorhexidine antisepsis kits in carts or grab bags storing central line equipment. Many prepared central line kits include povodine-iodine kits and these must be avoided. Ensure that solution dries completely before attempting to insert the central line.

18. Central Line Site Selection Whenever possible, and not contraindicated, the subclavian line site should be preferred over the jugular and femoral sites for non- tunneled catheters in adult patients. Vanderbilt Infection Control & Prevention

19. Daily Review of CL Necessity Include daily review of line necessity as part of your multidisciplinary rounds. 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. Vanderbilt Infection Control & Prevention

20. Create Redundancy Develop strategy to ask daily if lines can be removed Daily Goals Nursing/physician sign outs on Rounds Implement checklist to be completed at time of insertion Nurses present during line insertion Support for speaking up Modify checklist for local use Vanderbilt Infection Control & Prevention

21. Getting Started Do Your Homework First!! Interdisciplinary team Gain consensus on plans Create timeline for deliverables Vanderbilt Infection Control & Prevention

22. Start Small Select the team and the venue. It is often best to start in one ICU. Many hospitals will have only one ICU, making the choice easier. Assess where you stand presently. What precautions are taken presently when placing lines? Is there a process in place? If so, work with staff to begin preparing for changes. Contact your Infection Control Department. Learn about your catheter-related bloodstream infection rate and how frequently the hospital reports it to regulatory agencies. Organize an educational program. Teaching the core principles to the ICU staff will open many people’s minds to the process of change. Introduce the central line bundle to the staff. Vanderbilt Infection Control & Prevention

23. First Test of Change Begin using the bundle with one patient from the time of catheter placement. Work with each nurse who cares for the patient to be sure they are able to follow the bundle and implement the checklist and daily goals sheet. Make sure that the approach can be carried over from shift to shift to eliminate gaps in teaching and utilization. Process feedback and incorporate suggestions for improvement. Vanderbilt Infection Control & Prevention

24. One ICU…then the Rest Once the bundle has been applied to one patient and subsequent shifts, increase utilization to the remainder of the ICU. Engage in additional PDSA cycles to refine the process and make it more reliable. After achieving reduction in CR-BSI in the pilot ICU, spread the changes to other ICUs, and eventually to other places in the hospital where central lines are inserted …So Use Data Vanderbilt Infection Control & Prevention

25. CLABSI per 1000 Line Days CLABSI X 1000 CL Days How do I get the central line days? Get ICU staff involved Unit secretary counts # lines each day at 12MN Charge nurse counts each day at change of shift See if IT can give you the numbers electronically Vanderbilt Infection Control & Prevention

26. Potential Barriers Fear of change Use knowledge Use optimism Communication breakdown Involve all stakeholders on the front end MD and staff partial “buy-in” Supply continuous data to all groups Changes in rates convert the non-believers Vanderbilt Infection Control & Prevention

27. Questions? Vanderbilt Infection Control & Prevention