Why Maintenance is so High Maintenance: How to Achieve Success Tamara Johnson RN Director Clinical Integration Ivera Medical Corporation

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)

Clabsi timeline 2001 – Beginning of the term “Never Events” 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 2012 – Updated CLABSI Definitions from CDC National Quality Forum – coalition of public and private healthcare sector leaders who are focused on ensuring healthcare quality and patient protection by providing measurement capabilities and public reporting CEO – Ken Kizer AHRQ – request to reduce infections by 50% by 2013 2013 – Updated CLABSI Definitions from CDC 2014 – Updated CLABSI Definitions from CDC

From our friends at the cDC… 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 1. ) http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf

A reminder about Great Vessels1 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 1. ) http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf

A central line includes: Central Venous Catheter (CVC) Peripherally Inserted Central Catheter (PICC) Dialysis Catheter Umbilical Catheter Hickman Catheter Broviac Catheter Groshong Catheter

Impact of CLabsi $34, 500 - $56, 000 per episode2 $54,000 - $75,000 in adult Surgical ICU3 80,000 ICU BSI’s a year – leading cause of ICU nosocomial infections4 250,000 CLABSI’s a year2 30,665 deaths a year from CLABSI5 2.) Moreau N. Nursing 2009;34:14-15 3.) Hollenbeak CS. J Infus Nurs. 2011:3309-3313 4.) O’Grady NP, et al. American Journal Infection Control 2011;39(4suppl 1):51-34 5.) Klevens RM, et al. Public Health Rep. 2007;122-160-166

Mechanisms leading to clabsi6 Pathogen migration along external surface – typically within first 7 days Hub contamination leading to intraluminal colonization Needleless connector contamination leading to intraluminal colonization Established from a different source Contaminated infusions 6.) The Joint Commission. Preventing Central Line–Associated Bloodstream Infections: A Global Challenge, a Global Perspective. Oak Brook, IL: Joint Commission Resources, May 2012. http://www.PreventingCLABSIs.pdf.

Protecting our patients… Implementation of “Bundles” Bundle7 - 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 Institute for Healthcare Improvement 7.) http://www.ihi.org/explore/bundles/Pages/default.aspx

CLABSI Bundles Central Line Insertion Practices (CLIP)8 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 8.) http://www.cdc.gov/nhsn/PDFs/pscManual/5psc_CLIPcurrent.pdf

CLIP vs maintenance 1 vs ??? Extraluminal vs Intraluminal CLIP = happens one time on a patient Maintenance = happens all day long by a lot of different people (#1) 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

Central Line Maintenance “GUIDELINES” 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 ✔ #2 9.) http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html

Needleless connector disinfection 2007 Java Vol 12, No 3, 140-142

“Scrub the HuB” 15 seconds

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) #3

And the survey says…

Challenges with claBSIs Many Ports of Entry into the bloodstream #4

Challenges with Clabsi Cannot See Microorganisms – blessing and curse #5 Culture from a patient’s needleless connector. – Wendy Kaler, MT, MPH, CIC

Challenges with Clabsi No Immediate Accountability – Patient doesn’t yell OUCH! #6

Challenges with Clabsi Dynamic Bedside environment – nurse gets interrupted every two minutes #7

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

How a port protector works Passive Disinfection Chemical agent – 70% Isopropyl Alcohol Time of exposure – 3 - 5 minutes (per DFU) Physical barrier – up to 4 - 7 days if not removed (per DFU) No scrubbing necessary (for first access) FDA 510(k) Single use

Types of Port Protectors

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 07.04.01 Peer Reviewed Data Studies have demonstrated reduction in CLABSI, Contaminated Blood Cultures, and Intraluminal contamination What’s next?

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 Possible reduction in CLABSI Cost savings Length of stay decrease Readmission decrease Increase in Patient Satisfaction SAVED LIVES Possible reduction in contaminated or false positive blood cultures Reduction in unnecessary antibiotic usage

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 Possible reduction in CLABSI Cost savings Length of stay decrease Readmission decrease Increase in Patient Satisfaction SAVED LIVES Possible reduction in contaminated or false positive blood cultures Reduction in unnecessary antibiotic usage

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 Possible reduction in CLABSI Cost savings Length of stay decrease Readmission decrease Increase in Patient Satisfaction SAVED LIVES Possible reduction in contaminated or false positive blood cultures Reduction in unnecessary antibiotic usage

SIX SIGMA PROJECT – TX HOSPITAL 1. Open MAR 2. Scan Medication 3. Prepare Medication 4. Open Alcohol Pad = 66 sec per injection (Avg. time spent in 12hr shifts giving IV injections) 5. Scrub Hub for 15 sec 6. Dry for 15 sec 7. Administer Medication

Advantages to Port Protection 1. Open MAR 2. Scan Patient 3. Scan Medication 4. Prepare Medication = 23.7 sec per injection 6. Administer Medication 5. Remove Port Protector 7. Replace with new port protector 64 % reduction!

Even simple solutions have challenges The “Silver Bullet Syndrome” Hand Hygiene Clean, Dry, Intact Dressings Confusing Protocol Forced Compliance vs. Non-Forced Compliance

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

Main Challenge? IT ONLY TAKES EXPOSURE ONE #10

Thank You! Questions?

Challenge accepted Product Location Education – reinforce the “WHY” 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

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

Advantages to port protection Allows for complete compliance with JCAHO NSPG 07.04.01 Visual auditable tool (no shadowing!) Allows for documentation of standardized procedure and allows for reporting

COMMUNICATION The single biggest problem with is the illusion that it has taken place. - George Bernard Shaw

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

WEEKLY UNIT REPORTING

Celebrate successes

I don’t have time!

ORGANIZATIONS WHERE ONE breach in process CAN IMPACT lives…

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.

SHEA/IDSA Practice recommendations SHEA/IDSA Practice recommendations Infection control and hospital epidemiology, vol. 35, no. 7 (july 2014) pp. 753-771 2014 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

$$$ 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%)

CONCLUSION Important tools to assist 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

Any questions?