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

October 2, 2008 8

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

October 2, 2008 10

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

October 2, 2008 15

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

October 2, 2008 16

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

October 2, 2008 19

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

October 2, 2008 21

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

October 2, 2008 22

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)

October 2, 2008 23

Implementation of Bundles and Implementation of Bundles and Infection RatesInfection Rates

October 2, 2008 24

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

October 2, 2008 29

Benefits of Participating

• Faster learning and quicker gains

October 2, 2008 30

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 Chairdrcm@rogers.com

• Bruce Harries, Collaborative Directorbharries@telus.net

• Leanne Couves, Improvement Advisorlcouves@telus.net

• Ardis Eliasonaeliason@telus.net

October 2, 2008 34

CLI Faculty ContactsCLI Faculty Contacts

• Tracie Northwaytnorthway@cw.bc.ca

• Dr. Peter Skippenpskippen@cw.bc.ca