1. 1 © 2010 TMIT NQF-Endorsed ® Safe Practices for Better Healthcare Safe Practice 21 Central Line-Associated Bloodstream Infection Prevention Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections

2. © 2006 HCC, Inc. CD000000-0000XX 2 © 2010 TMIT Slide Deck Overview Slide Set Includes:  Section 1: NQF-Endorsed ® Safe Practices for Better Healthcare Overview  Section 2: Harmonization Partners  Section 3:The Problem  Section 4: Practice Specifications  Section 5: Example Implementation Approaches  Section 6: Front-line Resources

3. 3 © 2010 TMIT Safe Practice 21 Central Line-Associated Bloodstream Infection Prevention Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections NQF-Endorsed ® Safe Practices for Better Healthcare Overview

4. 4 © 2010 TMIT 2010 NQF Safe Practices for Better Healthcare: A Consensus Report 34 Safe Practices Criteria for Inclusion Specificity Benefit Evidence of Effectiveness Generalization Readiness

5. 5 © 2010 TMIT Culture SP 1 2010 NQF Report

6. CHAPTER 7: Healthcare-Associated Infections Hand Hygiene Influenza Prevention Central Line-Associated Blood Stream Infection Prevention Surgical-Site Infection Prevention Daily Care of the Ventilated Patient MDRO Prevention Catheter-Associated UTI Prevention Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition- and Site-Specific Practices Consent & Disclosure Wrong-site Sx Prevention Press. Ulcer Prevention VTE Prevention Anticoag. Therapy VAP Prevention Central Line-Assoc. BSI Prevention Sx-Site Inf. Prevention Contrast Media Use Hand Hygiene Influenza Prevention Pharmacist Leadership Structures and Systems Med. Recon. Culture CPOE Read-Back & Abbrev. Discharge Systems Patient Care Info. Labeling Diag. Studies Culture Meas., FB., and Interv. Structures and Systems Risk and Hazards Team Training and Skill Bldg. Nursing Workforce ICU Care Direct Caregivers Workforce CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 2: Creating and Sustaining a Culture of Safety (Separated into Practices]  Culture of Safety Leadership Structures and Systems  Culture Measurement, Feedback, and Intervention  Teamwork Training and Skill Building  Risks and Hazards CHAPTER 5: Information Management and Continuity of Care  Patient Care Information  Order Read-Back and Abbreviations  Labeling Diagnostic Studies  Discharge Systems  Safe Adoption of Computerized Prescriber Order Entry CHAPTER 6: Medication Management  Medication Reconciliation  Pharmacist Leadership Structures and Systems CHAPTER 8: Condition- and Site-Specific Practices Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Prevention Pressure Ulcer Prevention VTE Prevention Anticoagulation Therapy Contrast Media-Induced Renal Failure Prevention Organ Donation Glycemic Control Falls Prevention Pediatric Imaging Informed Consent Life-Sustaining Treatment Disclosure CHAPTER 3: Consent and Disclosure Informed Consent Life-Sustaining Treatment Disclosure Care of the Caregiver Consent and Disclosure Care of Caregiver MDRO Prevention UTI Prevention Falls Prevention Organ Donation Glycemic Control Pediatric Imaging

7. 7 © 2010 TMIT Safe Practice 21 Central Line-Associated Bloodstream Infection Prevention Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections Harmonization Partners

8. 8 © 2010 TMIT Harmonization – The Quality Choir

9. 9 © 2010 TMIT The Patient – Our Conductor

10. © 2006 HCC, Inc. CD000000-0000XX 10 © 2010 TMIT The Objective Central Line-Associated Bloodstream Infection Prevention  Prevent central line-associated bloodstream infections (CLABSIs)

11. 11 © 2010 TMIT Safe Practice 21 Central Line-Associated Bloodstream Infection Prevention Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections The Problem

12. © 2006 HCC, Inc. CD000000-0000XX 12 © 2010 TMIT The Problem

13. 13 © 2010 TMIT [http://online.wsj.com/article/SB10001424052970204488304574428950126681432.html]

14. 14 © 2010 TMIT [http://www.nytimes.com/2010/01/07/health/research/07infection.html?ref=todayspaper]

15. © 2006 HCC, Inc. CD000000-0000XX 15 © 2010 TMIT The Problem Frequency  5.3 infections per 1,000 catheter days in ICUs  At least 48% of ICU patients have CVCs  79,500 CLABSIs occur each year in ICUs [Pronovost, N Engl J Med 2006 Dec 28;355(26):2725-32]

16. © 2006 HCC, Inc. CD000000-0000XX 16 © 2010 TMIT The Problem Severity  Up to 35% mortality rate associated with CLABSIs  14,000 to 28,000 deaths each year occur due to CLABSIs [Dimick, Arch Surg 2001 Feb;136(2):229-34; Levinson, Adverse events in hospitals: state reporting systems, 2008; Pittet, JAMA 1994 May 25;271(20):1598-601; Renaud, Am J Respir Crit Care Med 2001 Jun;163(7):1584-90]

17. © 2006 HCC, Inc. CD000000-0000XX 17 © 2010 TMIT The Problem Preventability  Use maximal sterile barriers during CVC insertion  Skin should be prepared using a chlorhexidine- based antiseptic  Ultimately, the risk of CLABSIs can be minimized by removing catheters when they are no longer necessary [Humar, Clin Infect Dis 2000 Oct;31(4):1001-7; Hu, Am J Infect Control 2004 May;32(3):142-6; Lederle, Ann Intern Med 1992 May 1;116(9):737-8; Marschall, Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S22-30; Marschall, Am J Infect Control 2008 Dec;36(10):S172.e5-8]

18. © 2006 HCC, Inc. CD000000-0000XX 18 © 2010 TMIT The Problem Cost Impact  Direct financial cost of CLABSIs is estimated to be more than $9 billion annually  The excess direct hospitalization costs of CLABSIs range from $12K-$56K per incident [Stone, Am J Infect Control 2005 Nov;33(9):501-9; Klevens, Public Health Rep 2007 Mar-Apr;122(2):160-6; Dimick, Arch Surg 2001 Feb;136(2):229-34; Digiovine, Am J Respir Crit Care Med 1999 Sep;160(3):976-81; Warren, Crit Care Med 2006 Aug;34(8):2084-9]

19. 19 © 2010 TMIT Safe Practice 21 Central Line-Associated Bloodstream Infection Prevention Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections Practice Specifications

20. © 2006 HCC, Inc. CD000000-0000XX 20 © 2010 TMIT Additional Specifications

21. © 2006 HCC, Inc. CD000000-0000XX 21 © 2010 TMIT Safe Practice Statement Central Line-Associated Bloodstream Infection Prevention  Take actions to prevent central line-associated bloodstream infection by implementing evidence-based intervention practices [O’Grady, CDC MMWR, August 9, 2002/51(RR10);1-26; Marschall, Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S22-30; Institute for Healthcare Improvement, Central Line Bundle: IHI Improvement Map, 2010; Mermel, Clin Infect Dis 2009 Jul 1;49(1):1-45; Joint Commission Resources, National Patient Safety Goal: NPSG.07.04.01, 2010]

22. © 2006 HCC, Inc. CD000000-0000XX 22 © 2010 TMIT Additional Specifications Before Insertion  Educate healthcare personnel involved in the insertion, care, and maintenance of central venous catheters about CLABSI prevention [Warren, Chest 2004 Nov;126(5):1612-8; Marschall, Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S22-30; TMIT, Resources to Prevent Ventilator-Associated Pneumonia (VAP) and Central Venous Catheter-Associated Bloodstream Infections, 2008]

23. © 2006 HCC, Inc. CD000000-0000XX 23 © 2010 TMIT Additional Specifications At Insertion  Use a catheter checklist to ensure adherence with infection prevention practices  Perform hand hygiene prior to catheter insertion or manipulation  Avoid using the femoral vein for central venous access in adult patients [Tsuchida, Int J Nurs Stud 2007 Nov;44(8):1324-33; Yilmaz, J Parenter Enteral Nutr 2007 Jul-Aug;31(4):284-7; Smith, Am J Infect Control 2008 Dec;36(10):S173.e1-3; Goetz, Infect Control Hosp Epidemiol 1998 Nov;19(11):842-5; Merrer, JAMA 2001 Aug 8;286(6):700-7]

24. © 2006 HCC, Inc. CD000000-0000XX 24 © 2010 TMIT Additional Specifications At Insertion Cont’d  Have a catheter cart or kit easily accessible  Use maximal sterile barrier precautions during CVC insertion  Use chlorhexidine-gluconate 2% and isopropyl alcohol solution [Berenholtz, Crit Care Med 2004 Oct;32(10):2014-20; Hu, Am J Infect Control 2004 May;32(3):142-6; Young, Am J Infect Control 2006 Oct;34(8):503-6; Smith, Am J Infect Control 2008 Dec;36(10):S173.e1-3; Pronovost, Am J Infect Control 2008 Dec;36(10):S171.e1-5; Ruschulte, Ann Hematol 2010 Mar;88(3):267-72]

25. © 2006 HCC, Inc. CD000000-0000XX 25 © 2010 TMIT Additional Specifications After Insertion  Use a standardized protocol to disinfect catheter hubs, needleless connectors, and injection ports  Remove nonessential catheters  Use a standardized protocol for nontunneled CVCs in adults and adolescents for dressing care  Perform surveillance for CLABSI and report the data regularly to the units [Luebke, Am J Infect Control 1998 Aug;26(4):437-41; Lederle, Ann Intern Med 1992 May 1;116(9):737-8; Parenti, Arch Intern Med 1994 Aug 22;154(16):1829-32; Maki, Crit Care Med 1994;22:1729-37; Casey, J Hosp Infect 2003 Aug;54(4):288-93; Shapey, J Hosp Infect 2009 Feb;71(2):117-22; Garnacho-Montero, Intensive Care Med 2008 Dec;34(12):2185-93; Rasero, Haematologica 2000;85:275-9; Marschall, Am J Infect Control 2008 Dec;36(10):S172.e5-8; Marschall, Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S22-30; Rosenthal, Am J Infect Control 2008 Nov;36(9):627-37; Ruschulte, Ann Hematol 2009 Mar;88(3):267-72]

26. 26 © 2010 TMIT Safe Practice 21 Central Line-Associated Bloodstream Infection Prevention Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections Example Implementation Approaches

27. © 2006 HCC, Inc. CD000000-0000XX 27 © 2010 TMIT Example Implementation Approaches

28. © 2006 HCC, Inc. CD000000-0000XX 28 © 2010 TMIT Example Implementation Approaches  Empower clinical staff to stop the insertion procedure if protocol elements are not followed  Replace administrative sets not used for blood, blood products, or lipids at intervals no longer than 96 hours  Perform a CLABSI risk assessment  Consider use of antiseptic- or antimicrobial- impregnated CVCs in adult patients  Use chlorhexidine-containing sponge dressings for CVCs in patients older than two months of age [Gillies, Cochrane Database Syst Rev 2005 Oct 19;(4):CD003588; Labeau, Infect Control Hosp Epidemiol 2009 May;30(5):494; Hanna, J Clin Oncol 2004 Aug 1;22(15):3163-71; Rupp, Ann Intern Med 2005 Oct 18;143(8):570-80; Garland, Pediatrics 2001 Jun;107(6):1431-6; Levy, Pediatr Infect Dis J 2005 Aug;24(8):676-9; Halton, Crit Care 2009;13(2):R35; Ho, J Antimicrob Chemother 2006 Aug;58(2):281-7]

29. © 2006 HCC, Inc. CD000000-0000XX 29 © 2010 TMIT Example Implementation Approaches  Use antimicrobial locks for CVCs  Use antimicrobial ointments for hemodialysis catheter insertion sites  Disinfection of needleless access ports is important to the maintenance of central lines [Henrickson, J Clin Oncol 2000 Mar;18(6):1269-78; Safdar, Clin Infect Dis 2006 Aug 15;43(4):474-84; Labriola, Nephrol Dial Transplant 2008 May;23(5):1666-72; Zakrzewska, J Hosp Infect 1995 Nov;31(3):189-93; Riu, Nephrol Dial Transplant 1998 Jul;13(7):1870-1; Lok, J Am Soc Nephrol 2003 Jan;14(1):169-79; Kaler, Journal of the Association for Vascular Access 2007;12(3);140]

30. © 2006 HCC, Inc. CD000000-0000XX 30 © 2010 TMIT Example Implementation Approaches Strategies of Progressive Organizations  Empower clinical staff to “stop the line” to make sure that the practice is followed for every patient

31. 31 © 2010 TMIT Safe Practice 21 Central Line-Associated Bloodstream Infection Prevention Chapter 7: Improving Patient Safety Through the Prevention of Healthcare-Associated Infections Front-line Resources

32. 32 © 2010 TMIT [http://www.ncbi.nlm.nih.gov/pubmed/18840085; http://content.nejm.org/cgi/content/short/362/1/18]

33. 33 © 2010 TMIT [http://www.shea-online.org/about/compendium.cfm]

34. 34 © 2010 TMIT [http://www.shea-online.org/Assets/files/patient%20guides/NNL_CA-BSI.pdf]

35. 35 © 2010 TMIT [http://www.jointcommission.org/PatientSafety/SpeakUp/] Poster available in Spanish

36. 36 © 2010 TMIT http://www.ihi.org/imap/tool/#Process=e876565d-fd43-42ce-8340-8643b7e675c7

37. © 2006 HCC, Inc. CD000000-0000XX 37 © 2010 TMIT TMIT National Webinar Series Preventing CLABS Infections: Safe Patients, Smart Hospitals (Safe Practice 21)  Kathy Warye (Denise Graham, proxy) – Topic: APIC Resources for Targeting Zero HAIs  Peter J. Pronovost, MD, PhD – Topic: Topic: Safe Patients, Smart Hospitals  Deborah Baugher Hobson, BSN – Topic: Clinical Pearls for Nursing To Eliminate CLABSIs  Melinda Sawyer, RN, MSN – Topic: Clinical Pearls for Nursing To Eliminate CLABSIs  Patti O'Regan, ARNP, ANP, NP-C, PMHNP-BC, LMHC – Topic: The Role of the Patient Advocate  Go to: http://safetyleaders.org/webinars/indexWebinar_March2010.jsp (March 18, 2010)

38. © 2006 HCC, Inc. CD000000-0000XX 38 © 2010 TMIT NQF & TMIT National Webinar Series Updated 2010 CLABSI and SSI Practices: A New Standard of Care (Safe Practices 21-22)  Peter Angood, MD – Topic: HAI Clinical and Financial Implications and Policy Future  Rabih Darouiche, MD – Topic: New Highlights in Central Line-Associated Bloodstream Infection and Surgical-Site Infection Prevention  David Classen, MD, MS – Topic: Future Picture of Healthcare-Associated Infections  Mary Oden, RN, BSN, MHS, CIC – Topic: Challenges for Infection Preventionists  Jennifer Dingman – Topic: The Role of the Patient Advocate  Go to: http://safetyleaders.org/pages/idPage.jsp?ID=5986 (February 18, 2010)

39. © 2006 HCC, Inc. CD000000-0000XX 39 © 2010 TMIT TMIT National Webinar Series Healthcare-Associated Infection and You: Cleaner, Safer Care (Safe Practices 19-25)  Kathy Warye – Topic: Perspective on the Development of the Implementation Examples of the NQF Safe Practices  Peter Angood, MD – Topic: HAI National Attention and Harmonization  David Classen, MD – Topic: HAI Compendium Harmonization with the Safe Practices  Julianne Morath, RN – Topic: Implementation  Jennifer Dingman – Topic: Call to Action  Go to: http://www.safetyleaders.org/pages/idPage.jsp?ID=4932 (May 14, 2009)