Reducing Colon Surgical Site Infections: A Quality Improvement Initiative of Two Hospitals
Reducing Central Line Infections (CLI)tools.patientsafetyinstitute.ca/Communities/CLI/Shared...
Transcript of Reducing Central Line Infections (CLI)tools.patientsafetyinstitute.ca/Communities/CLI/Shared...
Reducing Central Line Infections (CLI)
National Call & WebinarOctober 2, 2008
October 2, 2008 2
Purpose
• By the end of this call, participants will have:– Understanding of SHN results related to CLI– Answers to common questions– An overview of emerging issues from the clinical
literature– Questions answered
October 2, 2008 3
Teams Continue to EnrollTeams Continue to EnrollSafer Healthcare Now! Overview Total # Enrolled Teams
September 2005 to July 2008
118
296
443
546579
628695
734789 817
860
933962 977
1004 1021
0
100
200
300
400
500
600
700
800
900
1000
1100
Total # of Enrolled Teams
Sep-05 Nov-05 Jun-06 Nov-06 Jan-07 Mar-07 Jun-07 Aug-07 Oct-07 Jan-08 Mar-08 Apr-08
May-08 Jun-08 Jul-08 Aug-08
Total at July, 2008
October 2, 2008 4
10Venous Thromboembolism
49MedRec (Long Term Care)
39National Collaborative on Falls in Long-Term Care
27Antibiotic Resistant Organisms (AROs)/MRSA
1,021*Total
118Prevent Ventilator-Associated Pneumonia175Prevent Surgical Site Infection92Prevent Central Line-Associated Bloodstream Infection334Prevent Adverse Drug Events through Medication Reconciliation121Improve Care for Acute Myocardial Infarction55Deploy Rapid Response Teams
Number of
Teams
Intervention
*Total at August 29, 2008
Safer Healthcare Now!Safer Healthcare Now!Enrollment by InterventionEnrollment by Intervention
October 2, 2008 5
Enrollment UpdateEnrollment Update
272**
Total
34*
Quebec
3314758
Healthcare Delivery Organizations[includes hospitals, agencies, services and regions (with one or more hospitals participating)]
AtlanticOntarioWest
* Data taken from Quebec Campaign**Total at August 28, 2008
October 2, 2008 6
1021Total
0Yukon
37Saskatchewan
1Northwest Territories
73Manitoba
131British Columbia
81Alberta
468Ontario
67Quebec
15Prince Edward Island
77Nova Scotia
30Newfoundland & Labrador
41New Brunswick
Number of TeamsProvince/Territory
Total at August 29, 2008
Enrollment by Province & TerritoryEnrollment by Province & Territory
October 2, 2008 7
Teams Working on Each InterventionTeams Working on Each Intervention
*Total at August 29, 2008
1021*296Total39Falls 10VTE49MedRec (LTC)27ARO/MRSA11842VAP17553SSI9235Central line33482Med Rec12143AMI5541RRT
Jul /08 Nov /05
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October 2, 2008 9
BSI Rate per 1,000 Line DaysINTERVENTION - 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-05
Dec-05
Jan-0
6Feb
-06Mar-
06Apr-
06May
-06Ju
n-06
Jul-0
6Aug
-06Sep
-06Oct-
06Nov
-06Dec
-06Ja
n-07
Feb-07
Mar-07
Apr-07
May-07
Jun-0
7Ju
l-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
Jan-0
8Feb
-08Mar-
08Apr-
08May
-08Ju
n-08
Jul-0
8Aug
-08Sep
-08Oct-
08Nov
-08Dec
-08Ja
n-09
Feb-09
Mar-09
Apr-09
May-09
Jun-0
9Ju
l-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Month
Blo
odst
ream
Infe
ctio
n R
ate
per 1
000
days
Local Team National Goal
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Compliance Insertion Bundle INTERVENTION - CLI MEASURE: 2.0 Central Line Insertion Bundle Compliance
0%
20%
40%
60%
80%
100%
120%
Nov-05
Dec-05
Jan-0
6Feb
-06Mar-
06Apr-
06May
-06Ju
n-06
Jul-0
6Aug
-06Sep
-06Oct-
06Nov
-06Dec
-06Ja
n-07
Feb-07
Mar-07
Apr-07
May-07
Jun-0
7Ju
l-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
Jan-0
8Feb
-08Mar-
08Apr-
08May
-08Ju
n-08
Jul-0
8Aug
-08Sep
-08Oct-
08Nov
-08Dec
-08Ja
n-09
Feb-09
Mar-09
Apr-09
May-09
Jun-0
9Ju
l-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Month
Perc
ent C
ompl
ianc
e
Local Team National Goal
October 2, 2008 11
Compliance Maintenance Bundle INTERVENTION - CLI MEASURE: 3.0 Central Line Maintenance Bundle Compliance
0%
20%
40%
60%
80%
100%
120%
140%
160%
Nov-05
Dec-05
Jan-0
6Feb
-06Mar-
06Apr-
06May
-06Ju
n-06
Jul-0
6Aug
-06Sep
-06Oct-
06Nov
-06Dec
-06Ja
n-07
Feb-07
Mar-07
Apr-07
May-07
Jun-0
7Ju
l-07
Aug-07
Sep-07
Oct-07
Nov-07
Dec-07
Jan-0
8Feb
-08Mar-
08Apr-
08May
-08Ju
n-08
Jul-0
8Aug
-08Sep
-08Oct-
08Nov
-08Dec
-08Ja
n-09
Feb-09
Mar-09
Apr-09
May-09
Jun-0
9Ju
l-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Month
Perc
ent C
ompl
ianc
e
Local Team National Goal
October 2, 2008 12
A Different View
October 2, 2008 13
October 2, 2008 14
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Posted QuestionsPosted Questions
• Use of dedicated TPN lines• Use of chlorhexidine on access sites• Care of central line inserted from other site• Wearing of jewelry during line insertion/CVC
care• Special considerations for pediatric and
oncology population• Site selection • Use of ultrasound
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Dedicated TPN Lumen TeamDedicated TPN Lumen Team• Single lumen catheters used for TPN, placed in subclavian and cared for by a
dedicated TPN team versus catheters for other purposes placed and maintained by surgical ICU staff. Resulted in 5-fold lower incidence of infections for TPN catheters. Conclusion suggested that a team approach improves care.Dimick, J., Swoboda, S., Talamini, M., Pelz, R., Hendrix, C., & Lipsett, M. (2003). Risk of colonization of central venous catheters: Catheters for total parenteral nutrition vs other catheters. American Journal of Critical Care,12: 328-335
• Nutrition CNS responsible for TPN and TPN lines reduced CRBSI from 52% to 2.3% over a 4 year period.
• Sutton, C., Garcea, G. , Pollard, C., Berry, D., and Dennison, A. (2005). The introduction of a nutrition clinical nurse specialist results in a reduction in the rate of catheter sepsis. Clinical Nutrition, 24(2), 220-223.
• Prospective review (32 mos) of CVC lines with TPN after inception of a parenteral & enteral nutrition team. Reduction of rate from 24% (6 mos pre-team review) to 3.5% or 2.39 per 1000 days.
• Fabion, W., Wesley, J., Khalidi, N., & Silva, J. (1986). Total parenteralcatheter sepsis: Impact of the team approach. Journal of Parenteral and Enteral Nutrition, 10(6), 642-645
October 2, 2008 17
Chlorhexidine Chlorhexidine
• (2007) Study comparing chlorhexidine versus alcohol for line access. CR-BSI reduction rate by over 77% with 3.15% chlorhexidine and 70% alcohol. 2.6 versus 10.2/1000 line days.Jarrell, N. and Maher, K. (2007). Minimizing the risk of catheter related blood stream infections from multiple line accesses in a pediatric cardiac intensive care unit . (Poster) Children's Healthcare of Atlanta and Emory University School of Medicine. Retrieved on October 1st, 2008 from http://www.solumed.net/pages/bibliographie/APIC%20handout-Final.pdf
• Meta-analysis demonstrated that chlorhexidine antisepsis reduced line infections by 50% versus proviodine/iodine in patients who require short-term catheterization.Chaiyakunapruk, N., Veenstra, D., Lipsky, B., and Saint, S. (2002). Antiseptics to prevent infection from intravascular catheters. Annals of Internal Medicine, 136(11), 126
October 2, 2008 18
Care of Central Line Inserted from other Site
What is measurement for?
Special Considerations for…• Pediatric population
– Securement of line– Dressings– Neonates
• Oncology population– Skin irritation
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Optimal Site of Insertion Optimal Site of Insertion (CRBSI perspective)(CRBSI perspective)
• In adults, subclavian > jugular > femoral• Old literature/unclear of insertion and
maintenance techniques• In pediatrics, more patient based vs. site
based
October 2, 2008 20
Recent Adult LiteratureRecent Adult Literature
• Prospective Observational study• 831 CVL’s and 4735 catheter days in 657
patients• 3 sites compared
– Overall rate of infection was 4.01/1000 catheter days
– Subclavian 0.88/jugular 0/femoral 2.98o No “statistically significant difference”
Deshpande KS et al. The incidence of infectious complications of central venouscatheters at the subclavian, internal jugular, and femoral sites in
an intensive care unit population. CCM 2005;33:13-20
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Recent Adult LiteratureRecent Adult Literature• RCT fem vs jugular for insertion of short
term dialysis – 750 patients from a network of 9 tertiary
university medical centres and 3 general hospitals in France
– First catheter placement for renal replacement therapy
– Randomized to receive jugular vs femoral vein catheterization by experienced operators
– Rates of catheter related BSI similar (2.3 vs 1.5 per 1000 line days)
Femoral vs Jugular Venous Catheterization and Risk of Nosocomial Events in AdultsRequiring Acute Renal Replacement Therapy
A Randomized Controlled Trial. JAMA 2008;299:2413-2422
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Recent Pediatric LiteratureRecent Pediatric Literature
• (Berenholtz SM et al. Eliminating catheter-related bloddstream infections in the intensive care unit. CCM 2004;32:2014-2020; McKee C et al. Reduction of catheter-associated bloodstream infections in pediatric patients: Experimentation and reality. PCCM 2008;9:40-46)
• (McKee C et al. Reduction of catheter-associated bloodstream infections in pediatric patients: Experimentation and reality. PCCM 2008;9:40-46)
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Implementation of Bundles and Implementation of Bundles and Infection RatesInfection Rates
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Placement using US GuidancePlacement using US Guidance
• In 2001, the Agency for Healthcare Research and Quality performed a review of a vast number of risk reduction strategies to see which ones were unequivocally supported by the evidence. They found 11 such practices. One of them was “Use of real-time ultrasound guidance during central line insertion to prevent complications.”
• Lots of literature regards benefits/minimal downsides apart from initial cost of machine
Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/TechnologyAssessment: Number 43. AHRQ Publication No. 01-E058, July 2001. Agency for Healthcare Research and
Quality, Rockville, MD
October 2, 2008 25
Antibiotic Coated Antibiotic Coated CVLCVL’’ss
• “Overall, AI-CVCs are clinically effective and relatively inexpensive and therefore their integration into clinical practice can be justified. However, the use of these anti-infective catheters without the appropriate use of other practical care initiatives will have only a limited success on the prevention of CRBSIs. Comparative trials are required to determine which, if any, of the treated catheters is the most effective.”
Hockenhull JC et al. The clinical effectiveness andcost-effectiveness of central venous catheters treated with anti-infectiveagents in preventing bloodstream infections: a systematic review and
economic evaluation. Health Technology Assessment 2008; Vol 12: No 12
Your Questions
Facilitated by Bruce Harries
October 2, 2008 27
Resources
• CLI Getting Started Kit & Worksheets– Updated in Fall 2008
• Communities of Practice
• Canadian ICU Collaborative Improvement Guide – available when enrolled
About the Canadian ICU About the Canadian ICU CollaborativeCollaborative
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Benefits of Participating
• Faster learning and quicker gains
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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!
October 2, 2008 31
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
October 2, 2008 32
Timelines for VAP & CLI SeriesTimelines for VAP & CLI Series
• Fall 2008 – watch for details on SHN website and CoP
• Nov – Informational Calls• Dec – Enrolment Deadline
• Jan 2009 – Learning Session 1• April – Learning Session 2• October – Learning Session 3• December – Collaborative Series ends
October 2, 2008 33
Planning Team Contacts
• Dr. Claudio Martin, Collaborative [email protected]
• Bruce Harries, Collaborative [email protected]
• Leanne Couves, Improvement [email protected]
• Ardis [email protected]
October 2, 2008 34
CLI Faculty ContactsCLI Faculty Contacts
• Tracie [email protected]
• Dr. Peter [email protected]