The 100,000 Lives Campaign: Prevent Central Line Infections

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The 100,000 Lives Campaign Prevent Central Line
Infections

• Institute for Healthcare Improvement

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Do Central Lines Cause Bloodstream Infections?

• Central venous catheters (CVCs) disrupt the
  integrity of the skin, making infection with
  bacteria and/or fungi possible.
• Infection may spread to the bloodstream and
  hemodynamic changes and organ dysfunction (severe
  sepsis) may ensue.
• Approximately 90 of the catheter-related
  bloodstream infections (BSIs) occur with CVCs.

Maki DG. Infections due to infusion therapy. In
Hospital Infections, Third Edition, Bennett JV,
Brachman PS (eds), Little, Brown, Boston 1992.
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Incidence and Risk

• 48 of ICU patients have central venous
  catheters, accounting for 15 million central
  venous catheter-days per year in ICUs.
• The case fatality rate for catheter-related
  bloodstream infections approaches 20.

Mermel LA. Ann Int Med. 2000132 391-402. Soufir
L et al. Infect Control Hosp Epidemiol. 1999
Jun20(6)396-401.
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Incidence and Risk

• Studies that control for underlying illness
  severity give lower estimates of attributable
  mortality.
• These data suggest that attributable mortality is
  between 4 and 20.
• Thus, between 500-4,000 U.S. patients die
  annually due to bloodstream infections.

Pittet D et al. JAMA. May 25 1994271(20)1598-16
01. Soufir L et al. Infect Control Hosp Epidemiol
1999 Jun20(6)396-401.
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Central Line Catheter-Related BSIs are Costly
Prolong Care

• Attributable cost per bloodstream infection is
  estimated to be 3,700 to 29,000.
• Nosocomial bloodstream infections prolong
  hospitalization by a mean of 7 days.

Pittet D, Tarara D, Wenzel RP. JAMA. May 25
1994271(20)1598-1601. Soufir L et al. Infect
Control Hosp Epidemiol 1999 Jun20(6)396-401.
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CR-BSI Risk Factors

• Risk Factors with Percutaneous Non-Tunneled
  Catheters
• Site of insertion Subclavian vein less risky
  than internal jugular or femoral vein
• Multiple ports/hubs More manipulation and
  contamination
• Parenteral feeding TPN and/or lipids
• Infection elsewhere Remote, e.g., UTI or wound

Mermel LA, Am J Med. Sep 16 199191(3B)197S-205S
McCarthy MC, J Parenter Enteral Nutr 1987
11259.
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Centers for Disease Control Guidelines

• Major areas of emphasis
• Education and training of providers who insert
  lines
• Maximal sterile barrier precautions
• Use of 2 chlorhexidine for skin antisepsis
• Avoid routine replacement, including replacing
  over a wire
• Consider antiseptic/antibiotic impregnated
  catheters if rate of infection remains high

OGrady NP. MMWR. Aug 9, 2002 51 RR10, 1-29.
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AHRQ-Sponsored Evidence Summary

• Attributable mortality is 4-20.
• Analyses of costs are very variable.
• Routine replacement does not reduce risk.
• Maximal barrier precautions reduce risk.
• CVCs coated with antiseptics or antibiotics might
  reduce risk but are expensive.
• Use of chlorhexidine skin prep reduces risk more
  than povidone-iodine.

Saint S. http//www.ahrq.gov/clinic/evrptfiles.ht
mptsafety
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Opportunity Knocks

• What if a series of interventions could markedly
  reduce the risk of BSI?
• What if those interventions were already readily
  available in hospitals?
• What if all of those interventions were done all
  of the time on each patient?

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Benefits of Reducing CR-BSI

• Better patient outcomes
• Reduced mortality
• Improved satisfaction
• Nursing
• Physician
• Patients and families
• Financial benefits

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The Central Line Bundle

• is a group of interventions related to
  patients with intravascular central catheters
  that, when implemented together, result in better
  outcomes than when implemented individually.

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What Is a Bundle?

• A grouping of best practices with respect to a
  disease process that individually improve care,
  but when applied together result in substantially
  greater improvement.
• The science behind the bundle is so well
  established that it should be considered standard
  of care.
• Bundle elements are dichotomous and compliance
  can be measured yes/no answers.
• Bundles eschew the piecemeal application of
  proven therapies in favor of an all or none
  approach.

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Central Line Bundle Elements

• Hand hygiene
• Maximal barrier precautions
• Chlorhexidine skin antisepsis
• Optimal catheter site selection, with subclavian
  vein as the preferred site for non-tunneled
  catheters in adults
• Daily review of line necessity with prompt
  removal of unnecessary lines

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But, Does It Work?

• ICUs that have implemented multifaceted
  interventions
• similar to the central-line bundle have nearly
  eliminated
• CR-BSIs.
• Berenholtz et al. Critical Care Medicine. 2004
  322014-2020.

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Outcome and Cost Impact

• Rate of CR-BSIs fell from 11.3 to 0 /1000
  catheter days.
• Prevented annually (estimated)
• 43 CR-BSIs
• 8 deaths
• Estimated savings to hospital 1,945,922

Berenholtz et al. Critical Care Medicine. 2004
322014-2020.
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Our Lady of LourdesCR-BSI Rate
Beginning of Collaborative
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Our Lady of LourdesDays Between CR-BSI
As of the last observation point on December 31,
2004, 166 days had passed since the last central
line-related BSI occurred on July 18, 2004.
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Hand Hygiene 101

• When caring for central venous catheters, cleanse
  hands with soap and water or an alcohol-based
  waterless hand cleaner
• Before and after palpating catheter insertion
  sites
• Before and after inserting, replacing, accessing,
  repairing, or dressing an intravascular catheter
• Palpation of the insertion site should not be
  performed after the application of antiseptic,
  unless aseptic technique is maintained.
• Cleanse hands if they are obviously soiled or if
  contamination is suspected.
• Cleanse hands between patients, after removing
  gloves and after using the bathroom.

OGrady NP. MMWR. Aug 9, 2002 51 RR10, 1-29.
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What are Maximal Barrier Precautions?

• For the Provider
• Hand hygiene
• Non-sterile cap and mask
• All hair should be under cap
• Mask should cover nose and mouth tightly
• Sterile gown and gloves
• For the Patient
• Cover patients head and body with a large
  sterile drape

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Impact of Maximal Barrier Precautions (MBR)
ORodds ratio MBR inserter washes hands and
wears mask, sterile gown, sterile gloves and
patients head body are covered with a large,
sterile drape.
Mermel LA, Am J Med. Sep 16 199191(3B)197S-205S.
Raad, Infect Control Hosp Epidemiol. Apr
199415(4 Pt 1)231-238.
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Chlorhexidine Skin Antisepsis

• Prepare skin with antiseptic/detergent
  chlorhexidine 2 in 70 isopropyl alcohol.
• Pinch wings on the applicator to pop the ampule.
  Hold the applicator down to allow the solution to
  saturate the pad.
• Press sponge against skin, apply chlorhexidine
  solution using a back and forth friction scrub
  for at least 30 seconds. Do not wipe or blot.
• Allow antiseptic solution time to dry completely
  before puncturing the site ( 2 minutes).

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Baseline Compliance with Best Practice

• In the Johns Hopkins study, providers were
  compliant
• with best practice during 62 of the observed
• procedures

Intervention
Berenholtz et al. Critical Care Medicine. 2004
322014-2020.
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CDC Recommendation Regarding Site Selection

• in adult patients, a subclavian site is
  preferred for infection control purposes,
  although other factors (e.g., the potential for
  mechanical complications, risk for subclavian
  vein stenosis, and catheter-operator skill)
  should be considered when deciding where to place
  the catheter.

OGrady NP. MMWR. Aug 9, 2002 51 RR10, 6.
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Key Change Central Line Checklist

• Have the nurse document compliance with the
  insertion criteria at the time of insertion.
• Create a culture of safety and prevention
• Empower nurses to stop line placement if improper
  techniques are used.
• Instruct supervisory staff in the use of critical
  communication strategies to facilitate important
  exchanges.
• e.g., The sterile field has been contaminated,
  rather than You contaminated the catheter!

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Checklist Elements

• Before the procedure, did they
• Use appropriate hand hygiene?
• Apply chlorhexidine as antiseptic to procedure
  site?
• Drape entire patient in a sterile fashion?
• During the procedure, did they
• Use sterile gloves, mask and sterile gown?
• Maintain a sterile field?
• Select the subclavian site for an adult patient,
  unless contraindications were noted?
• Verify Did all personnel assisting with
  procedure
• follow the above precautions?

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Daily Review of Line Necessity

• Use the Daily Goals sheet to prompt discussion of
  line removal.
• Avoid routine replacement of central lines, even
  over guidewires.

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To Be Successful

• Set an aim Reduce the incidence of central
  line catheter-related bloodstream infections
  using the central line bundle.
• Set a goal The rate of CR-BSI will decrease
  by 50 in one year using the central line
  bundle.
• Plan well Adopt a change methodology that
• accelerates improvement such as The Model for
  Improvement.

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Model for Improvement

• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in an
  improvement?

Act
Plan
PDSA cycles
Study
Do
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Me and What Army?

• Form a team
• Include a diverse staff
• MDs, RNs, other care providers
• Identify a project champion
• Someone who maintains visibility in the ICU
• Identify a process owner
• For concerns now and in the future

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Engage Stakeholders

• Identify stakeholders in intensive care
• 3 groups MDs, RNs, venous access teams
• Secure representation from each
• Facilitates physician buy-in
• Generates nursing support

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Role of Leadership

• Committed Staff cannot improve without
  supportive leadership.
• Set the standard This is how we will
  practice.
• Resources Make time to work on testing.
• Share data Motivate staff for change.

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Starting the Project

• Is there a method in place now?
• Know your baseline performance
• Randomly select the records of 20 patients who
  had central lines placed. Apply the measures to
  them.
• Be sure to check compliance with the total bundle
  as well, the all or none goal.
• Educate ICU staff (using your own data).

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Small Tests of Change

• Small tests... 1 RN, 1 MD, 1 patient
• Move on to pilot test in one ICU
• Refine the process.
• Test on all shifts.
• Test on all patients with central lines.
• Measure your results to know if a change was an
  improvement.

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Helpful ChangesCentral Line Insertion

• Use line carts and kits or grab bags.
• Standardize insertion procedures.
• Store all equipment in the same place.
• Include central line insertion checklists in the
  kits or on the cart.

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Supportive Interventions

• Multidisciplinary Daily Rounds
• An opportunity to assess bundle-related issues
• Invite and encourage the family to join in.
• Daily Goal Sheets
• Critical tool for verifying necessity of lines
• Link to ventilator bundle items if doing both
  interventions

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Measure CR-BSI per 1000 Line Days

• Central line catheter-related bloodstream
  infection rate per 1000 central line-days
• Numerator Number of central line
  catheter-related bloodstream infections x 1000
• Denominator Number of central line-days (total
  number of days of exposure to central venous
  catheters by all patients in the selected
  population during the selected time period)

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Measure Central Line Bundle Compliance

• Central line bundle elements in place
• Numerator Number of patients with central
  line bundle in place
• Denominator Total number of patients with
  central venous catheters on the day of the week
  of prevalence sample

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Our Lady of LourdesCentral Line Bundle Compliance
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Model for Improvement

• What did we accomplish?
• Was that change an improvement?
• What further changes will lead to more
  improvement?

Act
Plan
Study
Do
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Summary

• Central line infections are common.
• Proven strategies exist to decrease CR-BSI.
• Using the Central Line Checklist, most bundle
  elements are implemented. Add the Daily Goals
  sheet to verify necessity of all lines every day.
• Thousands of lives and millions of dollars can be
  saved with reliable adherence and bundle
  execution.

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Complete details about the 100,000 Lives
Campaign, including materials, contact
information for experts, and web discussions, are
available on the web at www.ihi.org.