Prevention of Central Line Associated Bloodstream Infections (CLABs)

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Prevention of Central Line Associated Bloodstream
Infections (CLABs)

• Quality and Patient Safety
• Effectiveness and Outcomes
• Beth Israel Medical Center
• Petrie and Kings Highway Divisions

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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.

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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

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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

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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

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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

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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

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Multi-disciplinary CLABs Team Members

• 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

• Physicians
• 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

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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.

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Multi-disciplinary CLABs TeamPrinciples

• 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.

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Multi-disciplinary CLABs TeamPrinciples

• Patient hospital length of stay, morbidity and
  mortality can be reduced through prevention of
  CLABs.
• We can reduce the Medical Centers costs incurred
  for the care of patients with CLABs.

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CLABs
BIMC USA
Patients in ICU with Central Line 40 48
CLABs Rate 3.8 4
Increase LOS 5 d 14 d

• Mortality 18
• ICU risk 8x gtnon-ICU
• Additional 40,000 to hospital costs
• Hospitals absorb the costs!

Nationally 80,000 CLABs in ICUs per year 14,500
CLABs deaths
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Costs Incurred For Care of Patients with CLABs
CLAB Patients
Discharges Per Year
Annual Incremental Costs
Incremental Cost Per CLAB Patient
94 ICU Beds
960,000
40,000
24
3,000
824 Non-ICU Beds
550,000
25,000
22
43,000
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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

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Beth Israel Medical CenterCLABs Prevention

• 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

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Beth Israel Medical CenterCLABs Prevention

• Nursing empowerment to monitor practices
• Nursing permitted to ask and stop other persons
  who do not follow appropriate practices
• Hand hygiene compliance

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Beth Israel Medical CenterCLABs Prevention

• 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

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Beth Israel Medical CenterCLABs
PreventionEducation and Recertification

• Standardization of Practices and Documentation
  but also
• Hospital Specific
• Department Specific
• Unit Specific

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2005 Infection Control Policyfor Prevention of
Intravascular Infection
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Beth Israel Medical CenterCLABs
PreventionEducation 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

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Procedure Competency Form
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Beth Israel Medical Center CLABs
PreventionEducation and Recertification
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Beth Israel Medical CenterCLABs
PreventionStandardization of Practices

• Enforcement of Policy and Procedure
• Procedure Note
• Insertion Kit
• Nursing Empowerment

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Central Line Insertion Kit
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Compliance - Central Line Bundle
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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)
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ResultsData from PDSA Cycles
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)
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ResultsData from PDSA Cycles

• 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

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Beth Israel Medical CenterCLABs Prevention
Unit Longest Duration of Days Without CLAB
CCU 644
ICU 601
ED 547
SICU 483
PICU 396
non-ICU 345
MICU 344
CSICU 300
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Beth Israel Medical CenterCLABs Prevention ICUs
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BETH ISRAEL MEDICAL CENTER CLABs Prevention CCU
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Beth Israel Medical CenterCLABs PreventionRoot
Cause Analyses

• Within 24 hours of a CLAB
• All involved patient care staff
• 4 12 persons
• ED, ICU, non-ICU
• 20 45 minutes
• Collaborative, non-punitive process

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Beth Israel Medical CenterCLABs PreventionRoot
Cause Analyses

• Process that generates sustainable fixes
• Avoid workarounds that are constantly repeated
• Knowledge gained from this process is shared with
  all

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Beth Israel Medical CenterCLABs PreventionRoot
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

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Beth Israel Medical CenterCLABs PreventionRoot
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

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Beth Israel Medical CenterCLABs PreventionRoot
Cause Analyses

• 2005
• Central Line Care
• Dressings
• Access
• Insertion Practices
• Maximal barrier precautions
• Supplies never an issue
• Certification of physicians

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Results - Data from PDSA Cycles ICU CLABs
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Beth Israel Medical CenterCLABs PreventionRoot
Cause Analyses

• 2006
• Central Line Care
• Dressings
• Access
• Maintaining the momentum

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Results - Data from PDSA Cycles ICU CLABs
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Beth Israel Medical CenterCLABs Prevention

• 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

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GNYHA/UHF CLABs CollaborativeParticipating
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

• 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. Josephs Medical Center, Yonkers
• St. Lukes - Roosevelt Hospital Center
• St. Luke's Cornwall Hospital

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

• Systematic model for change that would
• Meet needs of hospitals within the region
• Use existing staffing and financial resources

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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 patients bedside when needed
(creation of central line insertion kit).
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CLABs Collaborative Website http//jeny.ipro.org/
clabs
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Examples of Findings fromRoot Cause Analyses
Line Maintenance
Technique not adequate
Lack of Education and Staffing
Line not changed on timely basis
Not compliant with hand hygiene
Inexperienced residents and clinicians
Line inserted w/o sterile technique
Line in for too long
Clinicians not knowledgeable about Central Line
Bundle
Dressing not changed using aseptic techniques
Inadequate use of maximal barrier precautions
Nurses do not properly know how to change
dressings
IV tubing not labeled properly to change
Inadequate prep before insertion
MD does not get someone to assist with line
insertion
Line not manipulated appropriately
Femoral line chosen instead of subclavian
Nurses too busy to check change dressings
Central LineAssociated Bloodstream Infection
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Barriers and Solutions
Barrier
Solution

• Lack of Compliance
• Maintenance
• Technique

Development of central line insertion
maintenance kits
Creation of monitoring tools to assure compliance
with bundle components
Empowerment of nursing staff to stop procedure
when bundle not followed
Daily rounds to assess line necessity and assure
appropriate maintenance
Development of Department/Hospital-wide educationa
l programs re insertion and maintenance
Lack of Education Staffing
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 CDCs NHSN definitions
Monthly data fed back (CLAB infection rates) to
participating hospitals and staff
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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 lt0.0001)
• 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 lt0.0001)
• 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

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.
Includes data from 36 of the 38 original
participating hospitals
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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

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Thank You