Reducing Central Line Infections (CLI)

Reducing Central Line Infections (CLI)

National Call

September 5, 2007

September 5, 2007 2

Purpose

• By the end of this call, participants will have:– Updated information on the SHN Campaign,

Getting Started Kits and reporting worksheets – Heard successes and learnings from

Improvement Teams– Answers to your team’s questions about

intervention-specific changes and measurement– An understanding of benefits and expectations of

enrolling in the Canadian ICU Collaborative

September 5, 2007 3

Campaign Structure

Partner Network

Peer SupportNetwork

CAPHC

Measurement Working Group & CMT Education & Resource

Working Group

Clinical Support

Canadian ICU Collaborative

ISMPCanada

Operations

Teams

Other Canadian Faculty

Communication Working Group

Atlantic

NodeOntario

Node

Western Node

Campaign SupportSHN National Steering Committee

Secretariat - CPSI

Patients

CCHSA CIHI

QuebecCampaign

IHI

September 5, 2007 4

Teams Continue to EnrollSafer Healthcare Now! Overview Total # Enrolled Teams

September 2005 to August 2007

118

296

403443

491

546 557579

602

669695

718 734

628

0

100

200

300

400

500

600

700

800

Total # of Enrolled Teams

Sep-05 Nov-05 Mar-06 Jun-06 Aug-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 May-07 Jun-07 Jul-07 Aug-07

Updated August 21, 2007

September 5, 2007 5

Safer Healthcare Now! Enrollment by Intervention

Intervention Number of Teams

Deploy Rapid Response Teams 52

Improve Care for Acute Myocardial Infarction 111

Prevent Adverse Drug Events through Medication Reconciliation

282

Prevent Central Line-Associated Bloodstream Infection 66

Prevent Surgical Site Infection 129

Prevent Ventilator-Associated Pneumonia 94

Total 734

As at August 21, 2007

September 5, 2007 6

Safer Healthcare Now! Enrollment by Province & Territory

Province/Territory Number of Teams

New Brunswick 24

Newfoundland & Labrador 16

Nova Scotia 56

Prince Edward Island 11

Quebec 22

Ontario 278

Alberta 63

British Columbia 118

Manitoba 55

Northwest Territories 1

Saskatchewan 22

Yukon 1

Total 669As at May, 2007

September 5, 2007 7

West Ontario Atlantic Quebec

Total

Healthcare Delivery Organizations [includes hospitals, agencies, services and regions (with one or more hospitals participating)]

53 115 25 17 210*

*Total at August 21, 2007

Enrollment Update

September 5, 2007 8

INTERVENTION - CLI MEASURE: 1.0 Central Line-Associated Primary Bloodstream Infection (BSI) Rate per 1000 Central Line-Days

0

1

2

3

4

5

6

7

8

9

10

Nov-0

5

Dec-0

5

Jan-

06

Feb-0

6

Mar

-06

Apr-0

6

May

-06

Jun-

06

Jul-0

6

Aug-0

6

Sep-0

6

Oct-06

Nov-0

6

Dec-0

6

Jan-

07

Feb-0

7

Mar

-07

Apr-0

7

May

-07

Jun-

07

Jul-0

7

Aug-0

7

Sep-0

7

Oct-07

Nov-0

7

Dec-0

7

Jan-

08

Feb-0

8

Mar

-08

Apr-0

8

May

-08

Jun-

08

Month

Blo

od

stre

am In

fect

ion

Rat

e p

er 1

000

day

s

Local Team National Goal

CLI Rate

September 5, 2007 9

Insertion Bundle Compliance

INTERVENTION - CLI MEASURE: 2.0 Central Line Insertion Bundle Compliance

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Nov-0

5

Dec-0

5

Jan-

06

Feb-0

6

Mar

-06

Apr-0

6

May

-06

Jun-

06

Jul-0

6

Aug-0

6

Sep-0

6

Oct-06

Nov-0

6

Dec-0

6

Jan-

07

Feb-0

7

Mar

-07

Apr-0

7

May

-07

Jun-

07

Jul-0

7

Aug-0

7

Sep-0

7

Oct-07

Nov-0

7

Dec-0

7

Jan-

08

Feb-0

8

Mar

-08

Apr-0

8

May

-08

Jun-

08

Month

Per

cen

t C

om

pli

ance


September 5, 2007 10

Maintenance Bundle Compliance

INTERVENTION - CLI MEASURE: 3.0 Central Line Maintenance Bundle Compliance

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Nov-0

5

Dec-0

5

Jan-

06

Feb-0

6

Mar

-06

Apr-0

6

May

-06

Jun-

06

Jul-0

6

Aug-0

6

Sep-0

6

Oct-06

Nov-0

6

Dec-0

6

Jan-

07

Feb-0

7

Mar

-07

Apr-0

7

May

-07

Jun-

07

Jul-0

7

Aug-0

7

Sep-0

7

Oct-07

Nov-0

7

Dec-0

7

Jan-

08

Feb-0

8

Mar

-08

Apr-0

8

May

-08

Jun-

08

Month

Per

cen

t C

om

plia

nc

e



Updates to GSK

• Essentially unchanged since previous edition

• Suggestions for implementation:– Begin with insertion bundle– Standardize policies, equipment and cleaning

agents

• Suggestions for measurement:– Deviation from bundle components will assist

with strategizing for improvement


Updates to Measurement Worksheets

• Three worksheets for each measure: chart, data entry and submitted by

• Compliance to individual bundle components

• Instructions for new section


Resources

• CLI Getting Started Kit & Worksheets

http://www.saferhealthcarenow.ca/Default.aspx?folderId=82&contentId=180

• Communities of Practice

http://www.saferhealthcarenow.ca/Default.aspx?folderId=124

• Canadian ICU Collaborative Improvement Guide

Available when enrolled in the Collaborative

Questions


Success Stories

• Pediatric ICU’s

• Centre Hospitalier Régional de Lanaudière

T. Northway, RN, MSN, & A. Robin, RN, BScN, BC Children’s Hospital;E. Folz, RN, BScN, Alberta Children’s Hospital;

M. Golberg, RN, BScN, NP, Stollery Children’s Hospital;J. Plouffe, RN, BScN, NP, Winnipeg Children’s Hospital

Reduction of Catheter Related Blood Stream Infections

A Canadian National

PICU Collaborative Experience

October 2004 to October 2005


Incidence of CRBSI

• Comparatively high rate of CRBSI in PICU (NNIS 6.6/1000 CVC line days)

• CDC reports 5.3/1000 CVC line days adult ICU• Attributable cost approximately $34,500-$56,000 US• Increased LOS (3 weeks)• Estimated mortality rate 13% - 19% (child) & 12% -

25% (adult)

oElward, A et al. (2005). Pediatrics 115(4), 868-872.o(2007) http://www.edwards.com/Products/CentralVenous/VantexInservice.htm?wbc_purpose=Basic&WBCMODE=PresentationUnpublishedoSlonim, A et. Al (2001). Pediatric Critical Care Medicine 2, 170-174.oYogaraj, J. et al. (2002). Pediatrics 110(3), 481-485.


Aim and Goals/Objectives

Aim:• To reduce the incidence of catheter related

blood stream infections (CRBSI) within Canadian PICUs

Goals/Objectives:• To reduce the incidence of CRBSIs by 20%

to 50% within 12 months (October 2005)


Teams


CRBSI Improvement Bundles

Insertion Bundle• Hand Hygiene• Maximum Barrier

Precautions (Inserter & Patient)

• Chlorhexidine for Skin Prep

• Site selection

Maintenance Bundle• Hand Hygiene• Standardized Hub

Antisepsis • Standardized

Accessing of Line– Line set-up– Accessing hubs– Dressing & tubing

changes

• Daily Reviewing of Line Necessity


Changes Tested

AP

SD

AP

SD

AP

SD

D S

P A

AP

SD

AP

SD

AP

SD

D S

P A

Speci

fic T

est C

ycle

s

BaselineStream

EducationStream

Establish current reality

Adoption of insertion& maintenance bundles

Adoption of CDC definition

Handwashing campaign

Moving to a culture of safety

Celebrating successes!

Developing staff clinical champions

Increased understanding ofICU Collaborative & process

Awareness of current reality

Awareness of importanceOf CVC infections

Creating controversy through transparency!


AP

SD

AP

SD

AP

SD

D S

P A

AP

SD

AP

SD

AP

SD

D S

P A

Speci

fic T

est C

ycle

s

InsertionStream

MaintenanceStream

Creation of insertion bundle•Hand hygiene•Full barrier precautions•Site selection•Cleansing solution change

Standardize equipment:Creation of vascular access tray

Standardize equipment:Creation of line insertion cart

Create line insertion checklist

Culture shift: RNs halting insertion if insertion bundle violated

Let’s make it easy to do the right thing & difficult to do the wrong thing!Let’s make it easy to do the right thing & difficult to do the wrong thing!

Daily Goal Sheet to review line necessity

Standardized data collection

CVC Maintenance Bundle:•Hand hygiene•Line set-up (closed system)•Dressing & tubing changes• Standardized cleansing solution

CVC maintenance OSCE station at annual RN

competency validation days

Changes Tested


0

1000

2000

3000

4000

5000

Hosp A Hosp B Hosp C Hosp D Hosp E Hosp F

PICU Line Counts (June to Dec 2005)

Total line days9030

0

5

10

15


PICU Monthly CRBSI Incidence(June to Dec 2005)

Total CRBSI29

0.0

1.0

2.0

3.0

4.0

5.0


Cumulative CRBSI per 1000 line days (June to Dec 2005)

Group 3.2 CRBSI/1000 line

days

Collaborative Results


NNIS Benchmark6.6 per 1000 Line Days

June to Dec 2005:Period with existing 6 teams contributing data

Collaborative Results

Initial Learning Session (LS)

for CRBSI Collaborative

Preventing central line infections at the CSSSNL

Jean Levasseur MD


CSSSNL

• Large regional, community hospital• 275 acute care beds• 12 beds 8 ICU and 4 CCU beds• Closed Unit• Working on Collaborative projects since

2003


Aims and objectives

• Eliminating C.L. infections• Implementing the insertion bundle• Initiate the maintenance bundle


Results

• 9 months of surveillance (insertion bundle)– Hand washing– Strict sterile technique– Chlorhéxidine– Insertion site


Results

• Data collection sheets– Insertion technique– Insertion protocol


Results

• Insertion


Results

• Technique


ResultsResults

0

30

60

90

3 months 6 months 9 months

Hand washing


ResultsResults

0

32

63

95


Face mask


ResultsResults

0

32

63

95


Sterile gown


ResultsResults

0

32

63

95


Large sterile drape


ResultsResults

0

33

67

100


Clorhexidine


ResultsResults

0

18

37

55


Cap


0

25

50

75


Site SSC Site FEM

Results


Results

• During the last year :• NO line infections for lines inserted on the

unit• BUT, 4 line infections during the 24 months

of provincial surveillance for lines cared for on the unit.


Results

• Common points to infected lines :• Site• “Emergent” insertions


Results

Dx LOS GermSite

(days)Outcome

12005

VC Paralysis 67 Staph C- Fem. (2) Survived

22005

MVR 12 Candida Fem. (8) Died

32006

AAA 22 Staph C- IJ (6) Survived

42006

Urosepsis 16 Staph C- Fem. (3) Survived


Changes tested

Dedicated cart


Changes tested

Withdrawal of other products


Reminders...

• Technique


Patient Perspective

Results are posted


Lessons Learned

• Small changes can bring big results• The maintenance bundle has to be

implemented as soon as possible…


Remerciements

• Thanks to the fantastic and hard working CSSSNL ICU quality team.

About the Canadian ICU Collaborative


Benefits of Participating

• Faster learning and quicker gains


Benefits of Participating (continued)

• Face-to-face Learning Sessions• Evidence-based changes, ready to test and implement• Coaching from experienced Faculty on application of changes• Education and training on tools for improvement and

measurement• Advice on targeted strategies to overcome resistance and

address barriers• Monthly feedback on progress from the Collaborative Faculty• Monthly conference calls specific to challenges your team is

facing• A List-Serve that provides real-time sharing of information,

direct to your email Inbox• A website for storing and sharing your documents with others• A comprehensive Improvement Guide with examples,

checklists, tools• No cost to join!


Expectations for Participating Teams

• Commitment of a team sponsor• Full participation of a multidisciplinary team• Development of measures• Regular reporting of progress to the Faculty• Willingness and commitment to implement

rapid and widespread changes• Desire to innovate• Regular access to email and Internet


Collaborative Resources

• To Enroll

http://www.saferhealthcarenow.ca/Default.aspx?folderId=104&contentId=420

• About the ICU Collaborative

http://www.improvementassociates.com/dnn/Default.aspx?tabid=190

• About Breakthrough Series Collaboratives (general) http://www.ihi.org/IHI/Results/WhitePapers/TheBreakthroughSeriesIHIsCollaborativeModelforAchieving%20BreakthroughImprovement.htm

Questions


Contacts

• Bruce Harries, Collaborative Director

[email protected]

Reducing Central Line Infections (CLI)

Documents

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