Central Line Infections Avoidable Preventable

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Central Line InfectionsAvoidable? Preventable?
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• What is a CLC-RBSI?
• Can we avoid them?
• The IHI tools
• The UHW experience

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"When you can measure what you are speaking
about, and express it in numbers, you know
something about it." Lord Kelvin,
Popular Lectures and Addresses, 1889
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HCAI Surveillance

• In Wales the Welsh Assembly Government asked for
  the development of a mandatory HCAI surveillance
  programme for Critical Care in 2005

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• WCCIP established May 2006
• Aim to introduce care bundles into Critical
  Care in Wales
• CVC care bundle
• VAP care bundle

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WHAIP / WCCIP collaboration

• Development of surveillance programme to underpin
  the improvement work.
• Agreed definitions together
• All critical care units in Wales engaged and
  conducting surveillance in advance of the scheme
  becoming mandatory

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What is a CVC infection?

• Definitions
• CDC
• Nosocomial Infection National Surveillance Scheme
  (NINSS)
• HELICS

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• European surveillance scheme
• Allows benchmarking across Europe

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CVC surveillance introduced into mandatory HCAI
surveillance programme in Wales September
2007 VAP surveillance added September 2008
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Data collected on each patient with a CVC placed
on ICU or in-situ on arrival in ICU
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CVC Surveillance Results Sep 07 Dec 08
Patients in Wales in ICU with lines inserted
between 01/09/07 31/12/08
Provisional Data from the National Mandatory HCAI
surveillance programme, Wales - WHAIP team NPHS
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April 2008 April 2010
Reducing HCAI
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Content Areas

• Improving leadership for quality
• Reducing healthcare associated infections
• Improving critical care
• Improving medicines management
• Reducing surgical complications
• Improving general medical and surgical care
• Development Sites
• Trusts Only

Reducing HCAI
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What can cause CVC infection?

• Poor insertion hygiene
• Poor insertion technique
• Lack of appropriate skills
• Poor line maintenance
• Lines remaining in place for an inappropriate
  length of time
• Use of 3 way taps.......

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What is the cost to the patient?

• CLC-RBSIs are a major cause of morbidity
• A 2006 prevalence survey found that 42.3 of
  bloodstream infections in England are central
  line-related
• National Audit Office (2000) estimated the
  additional cost of a bloodstream infection to be
  6,209 per patient

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How to avoid/prevent Line Infections

• Standardise practice
• Practice variation is the enemy of quality
• Measure our practice and outcomes
• Know the extent of the problem in order to show
  improvement over time
• Develop a checklist model...... Care Bundle
• It makes the right thing to do the easy thing to
  do

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Care bundles explained

• A global standard of care management
• A group of interventions related to a disease
  process that when implemented together result in
  better outcomes than when implemented
  individually
• Bundle components can easily be measured as
  completed or not completed all-or-none
  compliance

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Bundle Aim

• To eliminate the piecemeal application of
  evidence-based guidelines that characterises the
  majority of clinical environments today
• To make it easier for clinicians to bring
  guidelines into practice

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What else is a bundle?

• Methodology to spread the use of generally
  accepted science

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What else is a bundle?

• Methodology to spread the use of generally
  accepted science
• Provide a pressure for teamwork

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What else is a bundle?

• Methodology to spread the use of generally
  accepted science
• Provide a pressure for teamwork
• Simple, memorable checklist

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What else is a bundle?

• Methodology to spread the use of generally
  accepted science
• Provide a pressure for teamwork
• Simple, memorable checklist
• Audit tool

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What else is a bundle?

• Methodology to spread the use of generally
  accepted science
• Provide a pressure for teamwork
• Simple, memorable checklist
• Audit tool
• All aspects should be done to get the maximum
  benefit

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Bundles bridge the Guideline Gap
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What makes a bundle so special?

• The power of a bundle
• science behind it
• method of execution with complete consistency 
• The changes in a bundle are not new theyre well
  established best practices, but theyre often not
  performed uniformly, making treatment unreliable
• A bundle ties the changes together into a package
  of interventions that people know must be
  followed for
• every patient
• every single time

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Types of Care Bundles

• Ventilator Care Bundle
• Sepsis Care Bundle
• Central Line Care Bundle

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CLC Bundle.....insertion

• Hand hygiene
• Decontaminate hands before and after each patient
  contact
• Use correct hand hygiene procedure
• Maximal barrier precautions
• PPE
• Single use gloves
• Eye/face protection
• Aseptic technique
• Sterile gown, gloves and full body drape
• Chlorhexidine skin antisepsis (2 Chlorhexidine
  Gluconate in 70 Isopropyl Alchohol)
• Catheter
• Optimal catheter site selection, with subclavian
  vein as the preferred site for non-tunnelled
  catheters
• Single lumen unless indicated otherwise
• Consider antimicrobial impregnated catheter if
  duration of 1-3 weeks and risk of CLC-RBSI high

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CLC Bundle....maintenance

• Hand hygiene
• Decontaminate hands before and after each patient
  contact
• Use correct hand hygiene procedure
• Catheter site inspection
• Regular observation for signs of infection ie.
  leakage, inflammation etc AT LEAST DAILY
• Dressing
• A sterile, transparent, semi-permeable dressing
  should be in place
• Ensure dressing is intact and dry
• Catheter access
• Aseptic technique swabbing ports/hubs with 2
  Chlorhexedine prior to access
• Administration set replacement
• Following administration of blood/blood products
  immediately
• Following TPN after 24 hours or 72 hours if no
  lipids
• All other fluid sets after 72 hours
• TPN should be infused via dedicated lumen
• Daily review of line necessity with prompt
  removal of unnecessary lines

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How to measure

• 1. Hand hygiene Yes No
• (hands washed alcohol gel used)
• 2. Maximal barrier precautions on insertion Yes
  No
• (user cap, mask, sterile gown, sterile
  gloves
• patient covered with large sterile drape)
• 3. Chlorhexidine skin antisepsis Yes No
  
• 4. Optimal catheter site selection Yes No
  
• (document site in notes reason for site
  selection)
• 5. Daily review documentation of line
  necessity Yes No
• (To be documented in patients notes)
• 6. Ultra sound used for insertion Yes No
  

Central Line Care Bundle
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Results

• Structure in place
• Process in place
• ........... will result in the desired outcome

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Structure

• Staff
• Equipment
• Documentation

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Process Measure

• Compliance with all elements of the CLC Care
  Bundle
• (insertion and maintenance)

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Outcome Measure

• Avoid / reduce Central Line Catheter-Related
  Blood Stream Infections (CLC-RBSI)

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• S P O

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How do we achieve reliable improvements to our
systems?

• Implementing evidence-based changes to improve
  patient outcomes
• Set time frames......how much, by when?
• Getting the data to show what impact the changes
  are having
• Spread

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The Three Fundamental Questions 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
  improvement?

Source, API The Improvement Guide, p. 10
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What are we trying to accomplish?
When you combine the 3 questions with the PDSA
cycle, you get
How will we know that a change is an improvement?
What change can we make that will result in
improvement?
the Model for Improvement.
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The PDSA Cycle for Learning and
Improvement
Act
Plan

• Objective
• Questions
• predications (why)
• Plan to carry out the cycle
• (who, what, where, when)
• Plan for data collection

• What changes
• are to be made?
• Next cycle?

Study
Do

• Complete the
• analysis of the data
• Compare data to
• predictions
• Summarize
• what was
• learned

• Carry out the plan
• Document problems
• and unexpected
• observations
• Begin analysis
• of the data

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Use the PDSA Cycle for

• Testing or adapting an improvement change
• Implementing the change
• Spreading the change to the rest of your system

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Repeated Use of the PDSA Cycle
Changes That Result in Improvement
DATA
Implementation of Change
Hunches, theories, best practices
Wide-Scale Tests of Change
Sequential building of knowledge under a wide
range of conditions
Follow-up Tests
Very Small Scale Test
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Use a PDSA form to organize, standardize and
document your tests!
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Plan

• Clear objective
• State predictions
• Who, what, where, when?
• Describe data collection plan

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Do

• Attempt to carry out plan
• Document any problems or unexpected events
• Collect planned data
• Capture feedback or observations from those
  conducting the plan
• Suggestions to improve in the DO phase of the PDSA

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Study

• Complete the analysis of the data
• Analyse feedback or observations
• Compare data/feedback to predictions summarise
  what was learned
• Suggestions

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Act

• What will happen in the next PDSA cycle?
• Develop change further?
• Test?
• Implement?

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PDSA example CLC Care Bundle
Routine use of CLC Bundle
DATA
Cycle 4 Repeat using 6 patients
Cycle 3 Repeat using 2 patients, doctors/nurses
for 1 week
Cycle 2 Repeat using 2 patients and 2
doctors/nurses for 2 days
CLC Bundle
Cycle 1 1 Doctor/1 Nurse / 1 patient/1 day use
of Chlorhexedine 2
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Multiple PDSA Cycles Running on Parallel Ramps
with Multiple Aims
Testing and adaptation
Alcohol gel each bed area
Coloured aprons
Use of Chlorhexedine 2
Stricter visiting times
Change Concepts
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Multiple PDSA Cycles Directed Toward a Single Aim
AIM
Concept C
Concept D
Concept B
Concept A
Change Concepts, Theories, Ideas
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What can you accomplish by Tuesday? It all
depends on the size and scope of the planned
change!
Start small
1 patient, 1 nurse, 1 doctor, 1 day
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UHW experience
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Structure and Process
Compliance with CLC Bundle
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Start small
1 doctor non-compliant
Lines Trolleys introduced
Dressing packs introduced
Compliance tick-box stickers
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Outcome
Zero CLC infections
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No agreed definition
National surveillance in Wales
HELICS agreed
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• A fundamental tenet of improvement in any
  industry is that if you want to improve you must
  develop a system to evaluate performance

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Future challenges
Spread
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References on Measurement and Improvement

• Brook, R. et. al. Health System Reform and
  Quality. Journal of the American Medical
  Association 276, no. 6 (1996) 476-480.
• Carey, R. and Lloyd, R. Measuring Quality
  Improvement in healthcare A Guide to Statistical
  Process Control Applications. ASQ Press,
  Milwaukee, WI, 2001.
• Langley, G. et. al. The Improvement Guide.
  Jossey-Bass Publishers, San Francisco, 1996.
• Lloyd, R. Quality Health Care A Guide to
  Developing and Using Indicators. Jones and
  Bartlett Publishers, Sudbury, MA, 2004.
• Nelson, E. et al, Report Cards or Instrument
  Panels Who Needs What? Journal of Quality
  Improvement, Volume 21, Number 4, April, 1995.
• Solberg. L. et. al. The Three Faces of
  Performance Improvement Improvement,
  Accountability and Research. Journal of Quality
  Improvement 23, no.3 (1997) 135-147.\
• Associate in Process Improvement. The Improvement
  Handbook Models, Methods and Tools for
  Improvement, Austin, TX, January 2005.

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