prevention of central line associated bloodstream infections (clabs) quality and patient safety...

Prevention of Central Line Associated Bloodstream Infections (CLABs)

Quality and Patient SafetyEffectiveness and Outcomes

Beth Israel Medical CenterPetrie and Kings Highway Divisions

CLABs Myths

Our infection rates are below national benchmarks - which is good enough.

CLABs are inevitable. It is the price we pay for sophisticated, complex care of severely ill patients.

CLABs are benign and readily treated with antibiotics.

CLABs are a common accompaniment of complex care and covered by outlier payments.

Lessons Learned

We can come surprisingly close to eliminating hospital acquired infections with determination as opposed to resources

Our data must not only be reportable but actionable Save lives Reduce costs Reduce error and waste

How We Did It

Make data actionable Observe variations in work practices Real time problem solving of origins of

CLABs Implement and test practice changes

Make Data Actionable

Start small Use and monitoring of evidence based

patient care practices or “bundles” with reporting back of data to end users

Counter measures generated by the people who do the work Process that generates sustainable fixes Avoid “workarounds” that are constantly

repeated Set a time to achieve goal

Plan-Do-Study Act (PDSA) methodology

Beth Israel Medical Center

Petrie Division Kings Highway Division

94 ICU beds 3,000 discharges

824 non-ICU beds 43,000 discharges

1,200 central lines placed annually 40% of patients in ICU with central line Average length of stay for patients with central line = 5 days Average length of stay for patients with CLAB = 10 days CLABs rate of 9 per 1,000 device days or 3.8% in 2004

Beth Israel Medical CenterCLABs Prevention

June 2005 ICU MICU, SICU

August 2005 CCU and CSICU

December 2005 Emergency Departments

January 2006 General Medical Surgical Units

April 2006 Operating Room

August 2006 NICU and PICU

Multi-disciplinary CLABs Team

MembersPhysicians Chief Medical Officer Associate Chairman, Department

of Medicine Director

ICU, MICU, SICU Emergency Room Medical and Emergency

Department Residency Programs Intensivist Critical Care Fellow

Infection Control Hospital Epidemiologist Manager Practitioner

Patient Care Services Vice President Director Nurse Manager

ICU, MICU, SICU Emergency Room

Nurse Education Manager

Other Director

Materials Management Housekeeping Respiratory Therapy Quality Improvement

Pharmacist Dietician

Multi-disciplinary CLABs TeamPrinciples

It is not good enough that our infection rates are below national benchmarks.

CLABs are preventable, they are not an inevitable consequence of sophisticated, complex care that we provide to our severely ill patients.


CLABs can be eliminated by determination as opposed to additional resources.

Strict adherence to evidence based patient care practices, called “bundles” that will improve patient safety and reduce adverse patient outcomes is required.


Patient hospital length of stay, morbidity and mortality can be reduced through prevention of CLABs.

We can reduce the Medical Center’s costs incurred for the care of patients with CLABs.

CLABs

Mortality = 18% ICU risk 8x >non-ICU Additional $40,000 to

hospital costs Hospitals absorb the

costs!

BIMC USA

Patients in ICU with Central Line

40% 48%

CLABs Rate 3.8% 4%

Increase LOS 5 d 14 d

Nationally: 80,000 CLABs in ICUs per year14,500 CLABs deaths

Used BI BSI information and discharge information from 2004

Costs Incurred For Care of Patients with CLABs

Annual Incremental

Costs

Incremental Cost Per

CLAB PatientCLAB

PatientsDischarges

Per Year

94 ICU Beds $960,000$40,000243,000

$1,510,000Total Incremental CLAB Costs

824 Non-ICU Beds

$550,000$25,0002243,000

Multi-disciplinary CLABs TeamAims and Goals

Process that generates sustainable fixes Avoid “workarounds” that are constantly

repeated Collaborative process Knowledge gained from this process is

shared with all Our data must not only be reportable but

actionable


Physician and Nurse reeducation and recertification on central line insertion technique and maintenance practices

Standardization of practices to ensure Maximal barrier protection utilized Skin prep with chlorhexidine Preference for subclavian site unless

medically contraindicated


Nursing empowerment to monitor practices Nursing permitted to ask and stop other

persons who do not follow appropriate practices

Hand hygiene compliance


Daily review of line necessity

Root cause analysis performed in real time for every CLAB

Development of a central line insertion kit Barrier precaution components Insertion components Maintenance components

Beth Israel Medical CenterCLABs PreventionEducation and Recertification

Standardization of Practices and Documentation but also:

Hospital SpecificDepartment SpecificUnit Specific

2005 Infection Control Policyfor Prevention of Intravascular Infection

BETH ISRAEL MEDICAL CENTER INFECTION CONTROL POLICY

MANUAL CODE: SUBJECT: Guidelines for Prevention of Intravascular Infection EFFECTIVE: February 2005 DISTRIBUTION: Nursing Units, Nursing Administration/Education Clinical Department Reviewed Revised 8/05 I. Handwashing

A. Wash hands with soap and water or use alcohol based hand rub solution prior to starting the procedure.

B. Verify the patient’s identity by name and birth, explain the procedure and obtain informed consent.

II. Surveillance for Catheter-Related Infection

A. Palpate the catheter insertion site for tenderness daily through the intact dressing. B. Visually inspect the catheter site if the patient develops tenderness at the insertion

site, fever without obvious source, or symptoms of local or blood stream infection.

III. Barrier Precautions During Catheter Insertion & Care

A. Wear clean gloves when inserting a peripheral venous catheter and during catheter dressing site changes required by the Occupational Safety and Health Administration (OSHA). Bloodborn Pathogens standard. Sterile Gloves are not required.

B. Use sterile technique, including the use of a sterile gown and gloves, a mask, cap,

and a large sterile drape (i.e., maximal barrier precautions) for the insertion of central venous lines including PICCs and guidewire exchanges. Use these precautions, even if the catheter is inserted in the operating room.

C. During central line catheter dressing site care, use a mask and sterile gloves.

IV. Selection of Catheter Insertion Site

DISTRIBUTION All Manual Holders PURPOSE To provide the Registered Nurse with the guidelines for dressing and cap change

on a central venous access device (includes single/double lumen catheters, implanted venous access ports, triple lumen catheters and PICC lines.)

POLICY This procedure may be performed by a Registered Nurse whose competence

has been demonstrated.

Central Venous Access Device dressings are changed at least every 7 days or if they become damp, soiled, loose or if inspection of the site or catheter change is necessary. In addition, dressings on implanted ports must be changed when the non-coring needle is changed once every five days. Caps must be changed whenever the integrity of the cap has been compromised but not less than once a week on Mondays.

EQUIPMENT A Dressing Change Tray (sterile) containing:

powder-free vinyl gloves (one pair) dressing ChloraPrep One-Step Biopatch® chlorhexidine foam pad

towel tape mask (optional) cotton tip applicator (optional)

clean gloves (one pair)

PROCEDURE KEY PONTS 1. Verify the patient’s identity by name

and date of birth.

2. Wash hands and don clean gloves.

3. Carefully remove the old dressing completely and discard.

Touch only the outer layer of the dressing to avoid contamination

4. Inspect the insertion site for color, tenderness, swelling or any discharge.

Look for leakage, swelling. bruising, tenderness, redness and general skin condition. Notify physician of any changes.

5. Remove gloves and wash hands

6. Open the Dressing Change Tray and don the sterile gloves

Strict aseptic technique is essential when carrying out any procedure involving central venous access catheter

7. Prep the skin with ChloraPrep One-Step

a. Pinch the wings on the applicator to break the ampule and release the antiseptic

Do not touch the sponge


Education and Recertification

Indications Anatomy Procedure

“Time Out” Universal Protocol Patient Position Skin Preparation Maximal Barrier Precautions Anesthesia Approach Dressing Additional Expectations

Clean up Monitor for complications

Procedure Competency Form Procedure Competency Form: Central Line /Transvenous Pacemaker Patient Addressograph Resident: ____________________ Observing Faculty: _______________________ Date: _______________________ Line Site: IJ R L

Subclavian R L Procedure: Central Line Femoral R L

Transvenous Pacemaker if femoral, reason for choice _____________________

Indication: ____________________________ # or Attempts _________ Time Out @ ___________AM/PM Verified Correct (all must be verified): Patient Procedure Site/Side

Position Supplies Equipment

_________________________ RN/MD ________________________RN/MD Consent Signed and In Chart Sterile Technique & Order of Procedure Operator / Sup Check

1. All equipment at bedside __________/______

2. Wash hands (before procedure) __________/______

3. Prep with Chlo-prep x 3 __________/______

4. Gown __________/______

5. Gloves __________/______

6. Cap __________/______

7. Drape __________/______

8. Time-out __________/______

9. Procedure with sterile technique __________/______

10. P lace Bio-patch __________/______

11. Dressing with date __________/______

12. Dispose sharps __________/______

13. Wash hands (after procedure) __________/______ ________________________________________________________________

Continued on Reverse Side

Assessment of Procedure

______ Informs patient of procedure including risks and benefits and obtains consent (if appropriate for circumstances)

______ Observes universal precautions ______ Positions patient properly ______ Maintains proper sterile technique ______ Uses ultrasound appropriately to identify vessel/patency ______ Central line flushed if appropriate ______ Skin prep appropriate for procedure ______ Appropriate local anesthesia ______ Needle aimed at proper angle and direction ______ Resident able to analyze and correct potential reasons for unsuccessful procedure ______ Venous blood obtained ______ Wire introduced and syringe removed ______ Skin cut made prior to inserting catheter dilator ______ Wire withdrawn as catheter advanced ______ Confirmation of port function ______ Catheter secured in place ______ Patient cleaned up and proper dressing applied ( Bio-Patch placed ) ______ Sharps disposed of in appropriate container ______ Confirmatory x-ray ordered and reviewed as necessary Assessment: Unsatisfactory Proficient Mastered

Comments:

Faculty Signature:________________________ Date: __________________ Resident Signature: _______________________ Date: __________________

Beth Israel Medical Center CLABs PreventionEducation and Recertification

Generated By: Beth Israel GME & Residency Manager

Procedure Report: Summary

05/03/06 05:40

Medical Resident KM Review Status Medicine

Procedure Logged Acc. Rej. Pend. No

Rev. Req. Exp. Compliance

Central Venous Line Placement - Femoral Line Insertion

2 0 0 0 2 5 NC (40%)

Central Venous Line Placement - Internal Jugular Insertion

1 0 0 0 1 5 NC (20%)

Central Venous Line Placement - Subclavian Insertion

6 6 0 0 6 5 C (100%+)

Beth Israel Medical CenterCLABs PreventionStandardization of Practices

Enforcement of Policy and ProcedureProcedure NoteInsertion KitNursing Empowerment

BETH ISRAEL MEDICAL CENTER VASCULAR ACCESS PROCEDURE NOTE

Date: _________________ Time Out at _______ AM/PM Verified Correct (all must be verified): Patient Procedure Site/Side Position Supplies Equipment _________________________ RN/MD ________________________RN/MD Central vein: R L Pulmonary artery: R L Transvenous pacemaker R L subclavian internal jugular femoral (if femoral, reason for choice) ________________________________________________________________ Arterial: R L radial femoral other_______________ Indication(s): _________________________________________________________ Consent in chart Operator(s): _______________________________________ Central Line Check List : 1- all equipments at bedside 8- Time-out 2- Wash hands 9- Mask 3- Chlor- prep 10- procedure with sterile technique 4- Gown 11- Bio-Patch 5- Gloves 12- Dressing with date 6- Cap 13- Dispose sharps 7- Drape 14- wash hands Anesthesia: _________________________________________________________ Technique: _________________________________________________________ Comments: ________________________________________________________ Complications: ______________________________________________________ __________________________________________________________________ Signature/Title Time:_______

Central Line Insertion Kit

Compliance - Central Line Bundle

0102030405060708090

100

Rate (% )

Aug Oct Dec Feb Apr Jun Aug

Time

ResultsData from PDSA Cycles

Number of CLABS

Costs of CLABS

2004 46 $1,510,000

2005 18 $705,000

2006 7 $392,000

2007 2 $112,000

Incremental cost per episode of CLAB ranges from $25,000 to $56,000(CDC data: Burke 2003)


Number of CLABS

Attributable Morbidity

and Mortality

2004 46 9

2005 18 4

2006 7 2

2007 2 0

Attributable morbidity and mortality: 12 – 25%(Wenzel 2001)


Significant reduction in CLABs 95% reduction for institution Achievement of zero CLABs on a variety of units Reduction in morbidity and mortality

Daily review of need for line necessity 20% decrease in central line days

Reduction in costs incurred in caring for patients with CLABs $1,500,000 costs avoided 90% reduction in costs from 2004 Costs to implement

Additional $15 per line inserted Total additional costs $30,000


Unit Longest Duration of Days Without CLAB

CCU 644

ICU 601

ED 547

SICU 483

PICU 396

non-ICU 345

MICU 344

CSICU 300

Beth Israel Medical CenterCLABs Prevention ICUs

0

1

2

3

4

5

2004 2005 2006 2007

Rate

Rate per 1,000 Line Days Rate per 100 Patients

BETH ISRAEL MEDICAL CENTER CLABs Prevention CCU

0

2

4

6

8

10

Q42005

Q12006

Q22006

Q32006

Q42006

Q12007

Q22007

Q32007

YEAR

Rate

per

1,0

00 lin

e d

ays

CCU NHSN NYS

Beth Israel Medical CenterCLABs PreventionRoot Cause Analyses

Within 24 hours of a CLABAll involved patient care staff

4 – 12 personsED, ICU, non-ICU20 – 45 minutesCollaborative, non-punitive process

Beth Israel Medical CenterCLABs PreventionRoot Cause Analyses

Process that generates sustainable fixesAvoid “workarounds” that are constantly repeatedKnowledge gained from this process is shared with all


Root Cause Analysis – August 2005

84 year old female with a history of hypertension, CHF, cardiac arrhythmia with pacer, insulin dependent diabetes

Admitted to ICU with CHF exacerbation, pleural effusion

Developed acute renal failure requiring dialysis Nephrologist places Shiley catheter Groin site chosen Difficult procedure requiring multiple attempts Maximal barrier precautions not fully utilized

Nursing staff attempt to assist Call intensivist to place line

Blood cultures positive for C. albicans 48 hours later


Root Cause Analysis – August 2005

Nephrologist conducts RCA Credentialed Central line indicated Urgent not emergent Supplies available and easily obtainable but not fully

utilized for maximal barrier precautions Need to ask for assistance sooner rather than later

Corrective Actions Central line insertion kit Nursing staff empowered and more comfortable with role Reeducation and recertification of nephrologist


Root Cause Analyses

2005 Central Line Care

Dressings Access

Insertion Practices Maximal barrier precautions Supplies never an issue Certification of physicians

Results - Data from PDSA Cycles ICU CLABs

0

2

4

6

8

10

2004 Q12005

Q22005

Q32005

Q42005

Q12006

YEAR

Rate

per

1,0

00 lin

e d

ays

ICU NHSN


Root Cause Analyses

2006 Central Line Care

Dressings Access

Maintaining the momentum

Results - Data from PDSA Cycles ICU CLABs

0

2

4

6

8

10

2004

Q1 20

05

Q2 20

05

Q3 20

05

Q4 20

05

Q1 20

06

Q2 20

06

Q3 20

06

Q4 20

06

Q1 20

07

Q2 20

07

Q3 20

07

YEAR

Rate

per

1,0

00 lin

e d

ays

ICU NHSN


Use and monitoring of evidence based patient care practices or “bundles” with reporting back of data to end users resulted in the rapid and sustained elimination or decreased incidence of CLABs on many units

Limited additional resources were necessary for the success of this initiative

Efforts were effective for all areas of the hospital where central lines are inserted

As compliance with insertion bundle improves, line maintenance has assumed a greater role in the prevention of CLABs

Culture change regarding goal of zero CLABs infections is applicable for all hospital acquired infections and patient safety issues

GNYHA/UHF CLABs Collaborative

Participating Hospitals• Beth Israel Medical Center• Bronx-Lebanon Hospital Center• Brookdale Hospital Medical Center• Cabrini Medical Center• Good Samaritan Hospital Medical Center• Interfaith Medical Center• Kingsbrook Jewish Medical Center*• Kingston Hospital*• Lenox Hill Hospital• Long Beach Medical Center• Long Island College Hospital• Lutheran Medical Center• Montefiore Medical Center• Mount Sinai Hospital• Mount Sinai Hospital of Queens• New York Downtown Hospital• New York Hospital Queens*• New York Methodist Hospital• New York-Presbyterian Hospital• New York University Medical Center• North General Hospital• Our Lady of Mercy Medical Center

• North Shore-Long Island Jewish Health System, including:

– Forest Hills Hospital– Franklin Hospital– Glen Cove Hospital– Huntington Hospital– Long Island Jewish Medical Center– North Shore University Hospital– Plainview Hospital– Southside Hospital– Staten Island University Hospital– Syosset Hospital

• Peninsula Hospital Center• Richmond University Medical Center*• Sound Shore Medical Center of

Westchester• St. Catherine of Siena Medical• St. Charles Hospital• St. Joseph’s Medical Center, Yonkers*• St. Luke’s - Roosevelt Hospital Center• St. Luke's Cornwall Hospital• St. Vincent’s Medical Center, Manhattan*• Stamford Hospital• The Parkway Hospital*• Trinitas Hospital• Winthrop University Hospital*• Wyckoff Heights Medical Center

*Hospitals that joined the CLABs Collaborative in the second round of participation (i.e., in August/September 2006).

GNYHA-UHF CLABs Collaborative Characteristics of Participating

Hospitals• 38 hospitals participating, 56 ICUs*• At inception of Collaborative, hospital practice was widely variable

across participants:

GREAT OPPORTUNITIES FOR IMPROVEMENT!

Area of Focus Consistently Use Inconsistently Use

Do Not Use

Daily Goals Sheet 21 7 26

Interdisciplinary Rounds 45 9 2

Central Line Bundle 11 27 17

Ventilator Bundle 16 30 10

Responses obtained from ICUs within participating hospitals.

*Note that these were responses from the original group of 38 CLABs Collaborative participating hospitals.

GNYHA-UHF CLABs Collaborative Design

• Systematic model for change that would

– Meet needs of hospitals within the region

– Use existing staffing and financial resources

GNYHA/UHF CLABs Collaborative Design

• Hospital leadership involvement and commitment• Interdisciplinary teams / Physician and Nurse champions• Evidence-based interventions: Implemented “Central Line Bundle”• 3 learning sessions: Reviewed key interventions for eliminating CLAB infections,

guidelines for inserting central line, materials needed, maintaining central lines, hospital best practices, and approaches to sustaining improvements.

• Bi-weekly conference calls: Shared information / tools specific to reducing CLAB infections.

• Collaborative web site for information-sharing: http://jeny.ipro.org/clabs • “Expert on Call” clinical consultant• Reinforcement of “zero tolerance” for CLAB infections• Standardized Materials: Teams developed and used standardized data collection

and definitions• Root Cause Analysis (RCA): Real time RCAs encouraged to identify reasons for

CLABs and develop solutions for prevention • Tracking Success: Aggregate and hospital-specific results reported monthly and

site visits made by Collaborative sponsors to identify areas in need of support

Central Line Bundle: Hospital teams identified the “central line bundle” as a strategy to prevent infection during central line insertion. Components include: hand hygiene, use of maximal barrier precautions,

chlorhexidine skin use, site of line placement, and review of line necessity. All necessary supplies should be available at the patient’s bedside when needed (creation of central line insertion kit).

http://jeny.ipro.org/clabs

CLABs Collaborative Website: http://jeny.ipro.org/clabs

http://jeny.ipro.org/clabs

Examples of Findings fromRoot Cause Analyses

Central Line–Associated Bloodstream Infection

Lack of Education and Staffing

Line Maintenance

Technique not adequate

Line not changed on timely basis

Dressing not changed using aseptic techniques

IV tubing not labeled properly to change

Line not manipulated appropriately

Line in for too long

Not compliant with hand hygiene

Line inserted w/o sterile technique

Inadequate use of maximal barrier precautions

Inadequate prep before insertion

Femoral line chosen instead of subclavian

Inexperienced residents and clinicians

Clinicians not knowledgeable about Central Line Bundle

Nurses do not properly know how to change dressings

MD does not get someone to assist with line insertion

Nurses too busy to check & change dressings

Barriers and Solutions

Barrier Solution

Development of central line insertion & maintenance kits

Creation of monitoring tools to assurecompliance with bundle componentsEmpowerment of nursing staff to stopprocedure when bundle not followed

Development of Department/Hospital-wideeducational programs re: insertion and maintenance

Lack of Education & Staffing

Daily rounds to assess line necessity and assure appropriate maintenance

Lack of Compliance•Maintenance•Technique

Reorganization of staffing to monitor and assure compliance

Creation of protocols in which nursing signs off on dressing rounds

Lack of Standardized Data Collection

Adoption of CDC’s NHSN definitions

Monthly data fed back (CLAB infection rates) to participating hospitals and staff

GNYHA-UHF Collaborative 15-Month Data Results*

Bundle Implementation1: • 88% reported full implementation; remaining 12% in process of fully implementing • Mean pre-bundle implementation CLAB infection rate = 4.02 infections / 1,000

central line days• Mean post-bundle implementation rate = 1.79 infections / 1,000 (p Value <0.0001)Overall Aggregate CLAB Infection Data: • Mean baseline rate = 4.86 infections / 1,000 central line days• Mean fifteen-month study period2 infection rate = 2.38 infections / 1,000• 51% overall decrease (p Value <0.0001)Comparison of CLAB Infection Data in 3-month Cohorts during 15-

month Study Period2: • Mean first three months (July through September 2005) = 3.10 infections / 1,000

central line days• Mean last three months (July through September 2006) = 1.76 infections / 1,000• 43% decrease during the course of the study period (p Value = 0.015)Maintaining Zero CLAB Infections during 15-month Study Period2: • 29 hospitals (81%) maintained zero for at least 3 months • 8 hospitals (22%) maintained zero during the last 6 months

*Includes data from 36 of the 38 original participating hospitals

Notes:

1 Bundle implementation, reported by 34 of the 38 original participating hospitals through an Interventions Survey developed by Collaborative sponsors, April 2006.

2 Study Period includes data collected by 36 of the 38 original participating hospitals from July 2005 through September 2006.

Monthly ICU Central Line Infection Rates for Hospitals Participatingin the GNYHA/UHF CLABS Quality Improvement Collaborative

Round 1 Hospitals

2.15

1.65

2.272.46

1.681.94 2.02

2.37

1.87

2.442.21

1.33

2.02

1.65

1.80

4.525.01 4.26

3.18

2.55

2.33

2.70

2.47

2.772.69 2.04

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Baseline Jul-05 Sep-05 Nov-05 Jan-06 Mar-06 May-06 Jul-06 Sep-06 Nov-06 Jan-07 Mar-07 May-07

Cen

tral

Lin

e In

fect

ion

s p

er 1

,000

Cen

tral

Lin

e D

ays

Monthly ICU Central Line Infection Rates for Hospitals Participatingin GNYHA/UHF CLABS Quality Improvement Collaborative

Round 2 Hospitals

5.13

2.62 1.88

0.88

4.75

2.45

3.31

1.73

0.68 0.81

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Baseline Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07

Cen

tral

Lin

e In

fect

ion

s p

er 1

,000

Cen

tral

Lin

e D

ays

Decreasing Incidence of MDROs!

BIMC Petrie KHD

MRSA 65% 50%

VRE 15% 25%

MDR Klebsiella 15% 20%

MDR Acinetobacter 45% 50%

C. difficile 10% 35%

Costs avoided: $1.5 million

Thank You

prevention of central line associated bloodstream infections (clabs) quality and patient safety...

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