1. An Evidence-Based Approach to the Maintenance Bundle Julie M. Weldon, MSN, RN Education Coordinator Mercy Medical Center Adjunct Faculty – Mercy College of Health Sciences Des Moines, Iowa jweldon@mercydesmoines.org 1

2. Learning Objectives Describe the elements of the insertion bundle, in efforts to reduce risk of CLABSI. Describe the elements of the maintenance bundle, in efforts to reduce risk of CLABSI Compare CDC and INS standards of practice for central line care. 2

3. Iowa population = 3.1 million Des Moines Metro Area = 569,633 3 18 network hospitals

4. Mercy Medical Center ~ Des Moines 649 staffed for 802 licensed beds, daily census > 500 2 campuses (downtown & west) About 1500 nurses 4 adult intensive care units (62 beds) 9 bed PICU, 22 bed Peds unit 64 room level 4 NICU 80 bed, 2 floor, maternal child unit Women's Services with 5137 deliveries in FY 2014 12 medical / surgical & telemetry units 4

5. Mercy Medical Center ~ Des Moines FY 2014 total discharges = 35,475 FY 2014 ED visits ~ 75,000 (30% admitted) FY 2014 Surgical Cases ~ 20,000 No Infusion Team; PICC Insertion Team – 3 full time nurses Average of 3000 PICC insertions per year Additional Central Line insertions by physicians 5

6. Central Venous Access Devices Central Venous Access Devices (CVADs) are also known as central venous catheters or central lines. Over 7 million lines are placed a year for short or long term use:  Medications, solutions  Chemotherapy  Blood, blood products  Parenteral nutrition  Ongoing therapy at home (CDC, 2011) 6

7. A Patient’s Perspective “I have survived for the past 10 years by infusion nutrition at home. This therapy is what sustains me, and requires central venous access. Catheter infections and other complications threaten my existence. Since I am unable to care for myself, I must rely on YOU for the best care possible, especially with regard to my central line.” Short cuts taken by healthcare providers may result in infusion complications, loss of the line, or loss of quality of life. 7

8. International Campaign Infusion complications are a global problem affecting all patient and healthcare demographics. Complications must be addressed globally in all settings in order to reduce mortality, especially from Central Line Associated Bloodstream Infections (CLABSI). 8

9. Infections, Just One Example In 2009 alone, an estimated 25,000 fewer CLABSIs occurred in the US ICUs than in 2001, a 58% reduction. In 2011, the CDC reported “12-25% mortality from CLABSIs. This represents 6,000 lives saved and excess health care costs. A substantial number of CLABSIs continue to occur…” (CDC, 2011) 9

10. Evidence-Based Infusion Care INS Standard of Practice 8 “The nurse shall use research findings and current best evidence to expand nursing knowledge in infusion therapy, to validate and improve practice, to advance professional accountability, and enhance evidence-based decision making.” 10 (INS, 2011)

11. It Starts with You! As leaders in vascular access, we need to be concerned this widespread risk exists. Promotion and education of basic principles for vascular catheter management is our responsibility to address. Use memorable tools like AVA’s “ I SAVE That Line!” or Oley’s “Save My Line – Save My Life!” 11

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14. Patient Care Education Patient education available from the OLEY Foundation. Found on their website: www.oley.org www.oley.org S = scrupulous hand hygiene A = aseptic technique V = vein preservation E = ensure patency 14

15. I Am Accountable for My Patient’s Care! Safety starts with me! What I permit, I promote! Many of the harms patients experience in healthcare are preventable. Quality may be defined as, “what happens when no one is watching”. Deviance from best practice must not be tolerated! 15

16. Implement Insertion Bundle Hand Hygiene Maximum Barrier Precautions Optimum Site Selection Daily Review of the Necessity of the Line (CDC, 2011 & INS, 2011) We participated in the Keystone ICU Initiative, 100K Lives & 5M Campaigns.

17. Insertion Bundle Thanks to the science behind the Insertion Bundle, the number of infections possible related to insertion technique has dropped. For example, only about 30% of the CLABSIs in our organization are identified within the first five days of insertion. 17

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19. Maintenance Bundle “SAVE” principles: S = Scrupulous Hand Hygiene A = Always Disinfect Every Needleless Connector (evidence demonstrates scrub at least 15 seconds or use passive disinfection) V = Vein Preservation E = Ensure Patency 19

20. Maintenance Bundle Standard of practice for tubing changes Standard of practice for changing needleless connectors and flushing Standard of practice for dressing changes  Skin antisepsis  Dressing change time frame  Securement device  Chlorhexidine dressing 20 (CDC, 2011 & INS, 2011)

21. Stages of CLABSI Interventions 1.Prior to 2006 = maximum barrier and insertion checklist 2.2006 – 06/2007 = Six Sigma Green Belt Project 3.07/2007 – 2008 = Project Improvements Implemented 4.2009 = PICC Catheter Conversion 5.06/2010 = changes to dressing change processes 6.07/2011 = “scrub the hub” and Huber needles 7.2012 = group chart review on all CLABSIs 8.07/2013 = tubing / dressing change work and CHG baths in adult critical care, TVU, PICU, 8S 9.03/2014 = IJ dressing application changes

22. Vascular Access Stabilization INS Standard of Practice 36 Practice Criteria C & D  “The use of alternative methods of vascular access device stabilization in lieu of sutures should be considered to mitigate the risk of needle stick injury…”  Use of any stabilization method should be based on evidence, as well as analysis of risks vs. benefits.” 22 (INS, 2011)

23. Vascular Access Stabilization In 2008, we introduced a PICC and central line dressing change kit to reduce variation in practice. From about 2008 – 2010, our PICC team was using one of the first stabilization devices out on the market. Our catheter dislodgement rate was 25%, causing us to re-evaluate our choice and review the evidence. 23 (Marschall et al, 2008)

24. Vascular Access Stabilization After several months of trial, in June of 2010 we changed our PICC dressing change kit with new securement to reduce our rate of accidental dislodgment. Within the first month, our accidental dislodgment rate for PICCs dropped to 0. It remains here today. Our physicians are slow to accept, and still suture other central lines. 24 (Wood, et al, 1997)

25. Vascular Access Stabilization In January of 2013, we participated in the 3M vascular access stabilization and dressing trial. Our PICC nurses completed head to head comparison of our current stabilization and the 3M stabilization. Also hoped to move physicians away from sutures. 25

26. Stabilization Trial Results No loss of line during the trial. No catheter migration during the trial. Wear time comparable. No skin integrity issues. Higher nurse satisfaction with ease of application & ease of removal. Higher patient satisfaction regarding comfort. 26

27. Vascular Access Device Site Care and Dressing Changes INS Standard of Practice 46 Practice Criteria B  “Central vascular access device site care and dressing changes should include the following: removal of the existing dressing, cleansing of the catheter-skin junction with appropriate antiseptic solution, replacement of stabilization device, and application of a sterile dressing.” 27 (INS, 2011)

28. Vascular Access Device Site Care and Dressing Changes INS Standard of Practice 46 Practice Criteria C  “Chlorhexidine solution is preferred for skin antisepsis”… “not recommended for infants under 2 months of age.” Practice Criteria E  “Transparent semipermeable dressings should be changed every 5-7 days, gauze dressings every 2 days.” 28 (INS, 2011)

29. Vascular Access Device Site Care and Dressing Changes INS Standard of Practice 46 Practice Criteria G  “Use of a Chlorhexidine-impregnated dressing with short-term CVADs should be considered in patients older than 2 months of age as an additional catheter-related bloodstream infection measure.” 29 (INS, 2011)

30. Vascular Access Device Site Care and Dressing Changes In 2010 while changing our stabilization device, we evaluated the various Chlorhexidine-impregnated dressings on the market. 30

31. Vascular Access Device Dressing Changes Review of the literature for studies with Chlorhexidine-impregnated dressings demonstrated similar efficacy when reducing bacterial counts at the insertion site. Compliance audits also play a factor. 31 (Garland et al, 2001) (Ho et al, 2006) (Levy, et al, 2005) (Timsit, et al, 2009) (Yong-Gang et al, 2009)

32. Vascular Access Device Dressing Changes At the time, we were inserting an average of 300 PICCs per month and averaged about 700 total PICC dressing changes per month. We have difficulty tracking how many physician inserted central lines averaged per month. We knew we used an average of 60 central line dressing change kits per month. 32

33. Change Management and Process Improvement Patient in the center of the process. Implement a structured, systematic approach to achieve operational excellence. Understand a defect-free process results from breakthrough improvement. Standardization eliminates variability in the process. Variability in the process results in errors. 33 (Eyberg, et al 2008) (INS, 2010)

34. Perseverance and Resilience 34 “Opportunity is missed by most people because it is dressed in overalls and looks like work.” ~ Thomas Edison

35. Financial Implications When comparing two different dressing change approaches and all things are clinically comparable, it is time to look at the initiative from the financial perspective. $ + $$ = $$$ vs. $ = $ 35

36. Our Decision 1.Clinical results similar according to the evidence. 2.Application of the dressing is “mistake proof”. 3.Price ~ given our volume, it was a $10,000 difference annually. 36

37. Our Volume CHG Dressing implementation in June 2010 Usage audit revealed 100% compliance of using dressing on all central lines during spot checks. House wide spot checks continued for 3 months. Using CY 2013 as our example…  31,713 “Central Line Days” by definition  13,177 dressings used 37

38. Maintenance Bundle For Mercy – Des Moines, following the evidence-based Maintenance Bundle is more is critical in comparison the evidence-based insertion bundle. Why???  70 % of our CLABSI in CY 2013 & 2014 had a dwell time of greater than 5 days. Introduced extended dwell midline and dressing change kit in October 2014. 38

39. IJ Dressing Issues Recent review of the literature revealed few interventions specific to patients with jugular central lines. Jugular lines are at higher risk than other insertion sites due to location near challenging care areas and patient anatomy. CLA-BSI patients in CSICU from calendar year 2013 with 10 CLABSI, 7 with IJ line. 39

40. IJ Dressing Improvements Multidisciplinary team included anesthesia, surgery nurses, CSICU nurses, nursing education coordinator and infection prevention. Team identified problems with central line dressing adherence for the jugular site. Nursing Education Coordinator re-educated staff on proper dressing application, including trial of skin prep prior to application. 40

41. IJ Dressing Improvements Patients with both jugular central line and CLABSI decreased from 7 (CY13) to 0 IJ infections (CY14 + year to date). 41

42. Stages of CLABSI Interventions 1.Prior to 2006 = maximum barrier and insertion checklist 2.2006 – 06/2007 = Six Sigma Green Belt Project 3.07/2007 – 2008 = Project Improvements Implemented 4.2009 = PICC Catheter Conversion, StatLock 5.06/2010 = changes to dressing change processes 6.07/2011 = “scrub the hub” and Huber needles 7.2012 = group chart review on all CLABSIs 8.07/2013 = tubing / dressing change work and CHG baths in adult critical care, TVU, PICU, 8S 9.01 - 03/2014 = IJ dressing application changes, extended dwell midline implementation

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44. An Evidence-Based Approach to the Maintenance Bundle Julie M. Weldon, MSN, RN Mercy Medical Center Des Moines, Iowa Education Coordinator Adjunct Faculty – Mercy College of Health Sciences jweldon@mercydesmoines.org jweldon@mercydesmoines.org 44

45. References Centers for Disease Control and Prevention. (2011) Guidelines for the prevention of intravascular catheter-related infections. MMWR, Vol. 51, 1-30. Centers for Disease Control and Prevention. (2011). Vital Signs: Central Line–Associated Blood Stream Infections — United States, 2001, 2008, and 2009. MMWR, March 4, 2011. Vol. 60, No. 8. Doellman, D. Pettit, J. Catudal, P. Buckner, J. Burns, D. Frey, AM. Runde, D. (2009). Pediatric CVC Maintenance Bundles. Pedivan. Eyberg, C.I……. Garland, J.S. Alex, C.P. Uhing, M.R. Peterside, I.E Rentz, A. Harris, M.C. (2001) Randomized trial comparing providone-iodine to chlorhexidine gluconate impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics, 107, 6, 1431-1436. Ho, K.M. ….. Infusion Nurses Society (2010). Infusion Nursing: An Evidence-Based Approach. Saunders Elsevier, St. Louis, 3rd edition, p. 395. Infusion Nurses Society (2011). Infusion Standards of Practice. Journal of Infusion Nursing. Supplement to January/February, vol. 34, n. 1S. Infusion Nurses Society (2011). Policies and Procedures of Infusion Nursing. 4 th edition. Joint Commission (2013). National Patient Safety Goals. www.jointcommission.orgwww.jointcommission.org 45

46. References Levy, I. Katz, J. Solter, E. et al. (2005) Chlorhexidine-impregnated dressings for prevention of colonization of central venous catheters in infants and children: a randomized controlled study. Pediatrics Infection Journal, 24, 8, 676-679. Marschall, J. Mermel, L.A. Classen D. (2008) Strategies to prevent central line – associated blood stream infections in acute care hospitals. Infection Control Hospital Epidemiology, v. 29, S22-S30. Oley Foundation (2013). Save My Line, Save My Life. www.oley.orgwww.oley.org Timsit, J.F. Bouadma, L. Ruckly, S. et al. (2012) Dressing disruption is a major risk factor for catheter-related infections. Critical Care Medicine, 40, 6, 1707-1714. Wood, D. And Bowe-Geddes, L. (1997). A Comparative Retrospective Analysis of Two Securement Techniques for Peripherally Inserted Central Catheters (PICC) and Midlines in the Home Care Setting. Journal of Association of Vascular Access, v 2, n 3. Yong-Gang, L…. 46