David Thompson, DNSc, MS, RN Kathleen Speck, MPH Sean Berenholtz, MD, MHS Johns Hopkins University School of Medicine Quality and Safety Research Group Using Evidence to Reduce Central Line Associated Blood Stream Infections.

The Problem is Large 16,000 CLABSI in U.S. ICUs annually Mortality: 18% (0-35%) Annual deaths: ,000 Cost per episode: $28,690-$56,000 Annual cost: $60 - $460 million BSI complications 43% of total cost –CDC. MMWR 2002; Heiselman JAMA 1994; Dimick Arch Surg 2001, Shannon Am J Med Qual 2006

What is the Evidence? Guidelines for the Prevention of Intravascular Catheter-Related Infections; Mermel LA. Prevention of Intravascular Catheter-related Infections. Ann Intern Med 2000;132:

Strategies for Prevention: 5 Key “Best Practices” Remove Unnecessary Lines Hand Hygiene Use of Maximal Barrier Precautions Chlorhexidine for Skin Antisepsis Avoid femoral lines * Line maintenance MMWR. 2002;51:RR-10

Hand Hygiene: The Evidence Since 1977, 7 prospective studies have shown that improvement in hand hygiene significantly decreases a variety of infectious complications Larsen. Clin Infect Dis 1999;29: Lancet 2000;356:

Washington Post ============================ August 5, 2008 HEADLINE: Hand Washing: Time Well Spent; We Need Carrots and Sticks to Reduce Infection Rates BYLINE: Manoj Jain, Special to The Washington Post

What are Maximal Barrier Precautions? For Provider: –Hand hygiene –Non-sterile cap and mask All hair should be under cap Mask should cover nose and mouth tightly –Sterile gown and gloves For the Patient –Cover patient’s head and body with a large sterile drape

Maximal Barrier Precautions Head to Toe!

Maximal Barrier Precautions: The Evidence 3.3 (p=0.03)CentralProspective Randomized Raad (p=0.03)SGProspective Cross-sectional Mermel 1991 OR for infection without MBP Type of Line Study DesignAuthor & Year Am J Med 1991;91(3B):197S-205S Infect Control Hosp Epidemiol 1994;15:231-8

Skin Prep: Chlorhexidine Ann Intern Med. 2002;136:

Skin Prep: Chlorhexidine Ann Int Med 2002;136:

What Site is Best? RCT of femoral and SC lines in the ICU –145 pts femoral/144 pts SC Outcomes –Higher rate of infectious complications in femoral grp: 19.8% vs.. 4.5% (p <.001) –Higher rate of thrombotic complications in femoral grp: 21.5% vs.. 1.9% (p <.001); complete thrombosis 6% vs. 0% –Similar rates of mechanical complication: 17.3% vs. 18.8% (p = NS) JAMA 2001,286:700-7

Our Baseline Compliance With Best Practice Two-week observation period –Physicians unaware of study 26 line insertions –8 (31%) new central venous access –18 (69%) for catheter exchanges over a wire –None were emergent Providers were compliant with best practice during 62% of the observed procedures* *National compliance estimated at 30%.

Systems Approach Every system is perfectly designed to get the results that it gets Bataldin, Vincent If you want to change performance you need to change the system

To prevent mistakes Shared Mental Model Create culture of safety Improve Processes –Reduce complexity –Create independent checks for key processes

Reduce Complexity Difficult to define who does/does not need central line New structure and process created: Patient- specific Daily Goals form and rounds –Is this catheter necessary? Line cart or kit: centralize supplies from 8 locations

Culture Training by Hospital epidemiology staff Web-based training Nurses assist with lines Nurses Maintained the lines Empower nurses to stop line placement

Improve Process Complexity –Line cart – store all equipment in one place Redundancy –Check list

Annals of Medicine The Checklist If something so simple can transform intensive care, what else can it do? by Atul Gawande December 10, 2007

CLABSI Rate VAD Policy Checklist Empower Nursing Line Cart Daily goals Crit Care Med 2004;32(10):2014..

Create Redundancy: CR-BSI Checklist Before the procedure, did they: –Wash hands –Sterilize procedure site –Drape entire patient in a sterile fashion During the procedure, did they: –Use sterile gloves, mask and sterile gown –Maintain a sterile field Did all personnel assisting with procedure follow the above precautions Nurses are empowered to stop non-emergent procedure if violation observed!!

Outcome and Cost Impact Rate of CLABSIs fell from 11.3 to 0 /1000 catheter days. Prevented annually (estimated): –43 CLABSIs –8 deaths –559 ICU days Estimated savings to hospital: $1,824,447 Benefits listed accrued from a single 12-bed ICU

Other Best Practices When adherence to aseptic technique cannot be ensured, replace all CVCs as soon as possible and after no longer than 48 hours Use CVC with the minimum number of ports or lumens Do not use topical antibiotic ointment or creams on insertion sites Do not routinely replace central venous or arterial catheters Replace all CVCs if the patient is unstable Use an antimicrobial or antiseptic-impregnated CVC if expected to remain in place >5 days and if, after implementing a comprehensive strategy, the CRBSI rate remains above goal. MMWR. 2002;51:RR-10

Summary Re-defining benchmarks Ensure patients receive evidence-based intervention –Culture –Complexity –Redundancy

All improvement is local: we can provide concepts; you need to design interventions

Central Line Dressing Change and Central Line Maintenance

Who Completes Nursing Personnel who have demonstrated competency for central line dressing changes, including PICC teams and Nurse practitioners. Medical personnel who have demonstrated competency including physicians and physician assistants. 3

Frequency Once weekly if a transparent dressing is used Every day if a gauze dressing is used while bleeding Any time a dressing is no longer occlusive, damp or visibly soiled. 4

Equipment Needed Chlorhexidine Gluconate 2% w/ Isopropyl Alcohol 70% (1 Swab)* –* if patient is sensitive, povidone iodine or 70% isopropyl alcohol may be used. –*do not use chlorhexidine in patients <2 years old. Sterile Gloves (appropriate size) Clean Gloves (appropriate size) Transparent dressing or gauze Mask for person applying dressing Cone mask for patient Skin prep Tape if gauze dressing is used 29

Additional Supplies that May Be Needed Sterile cotton tipped applicator (needed to cleanse insertion site) Sterile cup to hold sterile saline Sterile normal saline Adhesive removal pads or alcohol wipes Sterile 2x2 gauze

Procedure: Preparation 1.Explain procedure to patient/family. 2.Wash your hands. 3.Don clean gloves and remove old dressing using alcohol swab or adhesive remover pads as needed. 4.Inspect insertion site of catheter for signs of infection. Culture if needed. Assess security of sutures. 5.Remove your gloves. 6.Open sterile gloves and create a sterile field using sterile glove package. Continued… 31

Procedure: Sterilization 7.Open Chlorhexidine Gluconate 2% with Isopropyl Alcohol 70% swab and drop onto sterile field. 8.Open transparent dressing and drop onto sterile field. 9.Open skin prep and place on outer edge of sterile field. 10.Don sterile gloves. Continued… 32

11.Clean skin with Chlorhexidine Gluconate 2% with Isopropyl Alcohol 70% swab. 12.Using friction or scrubbing motion to apply. Begin directly at the insertion site as you move swab outward in a circular motion to cover all areas without retracing the area already cleansed. 13.Allow Chlorhexidine Gluconate 2% with Isopropyl Alcohol 70% swab to air dry completely.* * If using povidone iodine, allow to remain on the skin for at least 2 minutes, or longer until dry. Cleaning the Site

Preparing to Place Dressing 14.Designate one hand to be the unsterile hand and pick up the skin prep packet. 15.Remove skin prep pad with sterile hand. 16.Apply skin prep on outer perimeter of skin where dressing edge will touch patient. *Do not put skin prep over the catheter insertion site or the immediate surrounding area. Allow to completely dry. *Do not apply organic solvents (e.g., acetone or ether) to the skin before insertion of catheters or during dressing changes. 34

Replacement of IV Administration Sets Lipids and blood products (enhance bacterial growth) –Change every 24 hours All other IV administration sets –No more frequently than every 72 hours –Not more than every 96 hours 35

Hang Time for Parenteral Fluids Lipid-containing parenteral nutrition –Change every 24 hours All other IV fluids including nonlipid-containing parenteral nutrition –No formal recommendations –JHH changes nonlipid-containing IV fluids every 24 hours 36

Catheter Hub Cleansing Clean hub before accessing with Chlorhexidine or 70% alcohol No formal recommendations regarding how long to cleanse hub 37

Education: All necessary staff Guidelines to prevent catheter-related bloodstream infections Use of central line checklist Proper insertion and maintenance of central lines Ensure competency through yearly education and examination 38

Conclusions Applying a multifaceted quality improvement intervention designed to ensure 5 best practices ERADICATED, not merely reduced, CR-BSIs in a surgical ICU, a statewide cohort in Michigan and Adventist Health. Contradicts literature suggesting that CR-BSIs are expected due to patient factors, suggests more are due to faulty care than previously appreciated

References Johns Hopkins Hospital, Vascular Access Device Policy (Adult) H_Adult_VAD_Policy.pdf MMWR Guidelines for the Prevention of Intravascular Catheter-Related Infections Marschall J, Mermel LA, Classen D, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals. Infection Control and Hospital Epidemiology. 2008; 29 (supp. 1):S22-S30. O’Grady NP, Alexander M, Dellinger P, et al. Guidelines for the prevention of intravascular catheter-related infections. Infection Control and Hospital Epidemiology. 2002; 23(12):

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