Reducing Central Line Infections (CLI)

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Reducing Central Line Infections (CLI)

• National Call
• September 5, 2007

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Purpose

• By the end of this call, participants will have
• Updated information on the SHN Campaign, Getting
  Started Kits and reporting worksheets
• Heard successes and learnings from Improvement
  Teams
• Answers to your teams questions about
  intervention-specific changes and measurement
• An understanding of benefits and expectations of
  enrolling in the Canadian ICU Collaborative

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Campaign Structure
Campaign Support SHN National Steering
Committee Secretariat - CPSI
Clinical Support
CIHI
CCHSA
Operations
Quebec Campaign
IHI
Teams
Western Node
Atlantic Node
Patients
Canadian ICU Collaborative
Ontario Node
Other Canadian Faculty
Peer Support Network
ISMP Canada
Partner Network
CAPHC
Measurement Working Group CMT
Communication Working Group
Education Resource Working Group
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Teams Continue to Enroll
Updated August 21, 2007
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Safer Healthcare Now! Enrollment by Intervention
Intervention Number of Teams
Deploy Rapid Response Teams 52
Improve Care for Acute Myocardial Infarction 111
Prevent Adverse Drug Events through Medication Reconciliation 282
Prevent Central Line-Associated Bloodstream Infection 66
Prevent Surgical Site Infection 129
Prevent Ventilator-Associated Pneumonia 94
Total 734
As at August 21, 2007
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Safer Healthcare Now! Enrollment by Province
Territory
Province/Territory Number of Teams
New Brunswick 24
Newfoundland Labrador 16
Nova Scotia 56
Prince Edward Island 11
Quebec 22
Ontario 278
Alberta 63
British Columbia 118
Manitoba 55
Northwest Territories 1
Saskatchewan 22
Yukon 1
Total 669
As at May, 2007
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Enrollment Update
West Ontario Atlantic Quebec Total
Healthcare Delivery Organizations includes hospitals, agencies, services and regions (with one or more hospitals participating) 53 115 25 17 210
Total at August 21, 2007
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CLI Rate
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Insertion Bundle Compliance
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Maintenance Bundle Compliance
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Updates to GSK

• Essentially unchanged since previous edition
• Suggestions for implementation
• Begin with insertion bundle
• Standardize policies, equipment and cleaning
  agents
• Suggestions for measurement
• Deviation from bundle components will assist with
  strategizing for improvement

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Updates to Measurement Worksheets

• Three worksheets for each measure chart, data
  entry and submitted by
• Compliance to individual bundle components
• Instructions for new section

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Resources

• CLI Getting Started Kit Worksheets
• http//www.saferhealthcarenow.ca/Default.aspx?fol
  derId82contentId180
• Communities of Practice
• http//www.saferhealthcarenow.ca/Default.aspx?fol
  derId124
• Canadian ICU Collaborative Improvement Guide
• Available when enrolled in the Collaborative

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Questions
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Success Stories

• Pediatric ICUs
• Centre Hospitalier Régional de Lanaudière

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Reduction of Catheter Related Blood Stream
Infections

• A Canadian National
• PICU Collaborative Experience
• October 2004 to October 2005

T. Northway, RN, MSN, A. Robin, RN, BScN, BC
Childrens Hospital E. Folz, RN, BScN, Alberta
Childrens Hospital M. Golberg, RN, BScN, NP,
Stollery Childrens Hospital J. Plouffe, RN,
BScN, NP, Winnipeg Childrens Hospital
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Incidence of CRBSI

• Comparatively high rate of CRBSI in PICU (NNIS
  6.6/1000 CVC line days)
• CDC reports 5.3/1000 CVC line days adult ICU
• Attributable cost approximately 34,500-56,000
  US
• Increased LOS (3 weeks)
• Estimated mortality rate 13 - 19 (child) 12
  - 25 (adult)

• Elward, A et al. (2005). Pediatrics 115(4),
  868-872.
• (2007) http//www.edwards.com/Products/CentralVeno
  us/VantexInservice.htm?
• wbc_purposeBasicWBCMODEPresentationUnpublished
• Slonim, A et. Al (2001). Pediatric Critical Care
  Medicine 2, 170-174.
• Yogaraj, J. et al. (2002). Pediatrics 110(3),
  481-485.

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Aim and Goals/Objectives

• Aim
• To reduce the incidence of catheter related blood
  stream infections (CRBSI) within Canadian PICUs
• Goals/Objectives
• To reduce the incidence of CRBSIs by 20 to 50
  within 12 months (October 2005)

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Teams
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CRBSI Improvement Bundles

• Insertion Bundle
• Hand Hygiene
• Maximum Barrier Precautions (Inserter Patient)
• Chlorhexidine for Skin Prep
• Site selection

• Maintenance Bundle
• Hand Hygiene
• Standardized Hub Antisepsis
• Standardized Accessing of Line
• Line set-up
• Accessing hubs
• Dressing tubing changes
• Daily Reviewing of Line Necessity

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Changes Tested
Moving to a culture of safety
Creating controversy through transparency!
Adoption of insertion maintenance bundles
Celebrating successes!
Specific Test Cycles
Developing staff clinical champions
Adoption of CDC definition
Handwashing campaign
Awareness of current reality
Establish current reality
Increased understanding of ICU Collaborative
process
Awareness of importance Of CVC infections
Baseline Stream
Education Stream
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Changes Tested
Lets make it easy to do the right thing
difficult to do the wrong thing!
CVC maintenance OSCE station at annual RN
competency validation days
Culture shift RNs halting insertion if
insertion bundle violated

• CVC Maintenance Bundle
• Hand hygiene
• Line set-up (closed system)
• Dressing tubing changes
• Standardized cleansing solution

• Creation of insertion bundle
• Hand hygiene
• Full barrier precautions
• Site selection
• Cleansing solution change

Specific Test Cycles
Standardize equipment Creation of line insertion
cart
Standardized data collection
Create line insertion checklist
Daily Goal Sheet to review line necessity
Standardize equipment Creation of vascular
access tray
Insertion Stream
Maintenance Stream
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Collaborative Results
Total line days 9030
Total CRBSI 29
Group 3.2 CRBSI/1000 line days
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Collaborative Results
NNIS Benchmark 6.6 per 1000 Line Days
Initial Learning Session (LS) for CRBSI
Collaborative
June to Dec 2005 Period with existing 6 teams
contributing data
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Preventing central line infections at the CSSSNL

• Jean Levasseur MD

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CSSSNL

• Large regional, community hospital
• 275 acute care beds
• 12 beds 8 ICU and 4 CCU beds
• Closed Unit
• Working on Collaborative projects since 2003

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Aims and objectives

• Eliminating C.L. infections
• Implementing the insertion bundle
• Initiate the maintenance bundle

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Results

• 9 months of surveillance (insertion bundle)
• Hand washing
• Strict sterile technique
• Chlorhéxidine
• Insertion site

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Results

• Data collection sheets
• Insertion technique
• Insertion protocol

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Results

• Insertion

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Results

• Technique

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Results
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Results
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Results
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Results
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Results
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Results
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Results
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Results

• During the last year
• NO line infections for lines inserted on the unit
• BUT, 4 line infections during the 24 months of
  provincial surveillance for lines cared for on
  the unit.

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Results

• Common points to infected lines
• Site
• Emergent insertions

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Results
Dx LOS Germ Site (days) Outcome
1 2005 VC Paralysis 67 Staph C- Fem. (2) Survived
2 2005 MVR 12 Candida Fem. (8) Died
3 2006 AAA 22 Staph C- IJ (6) Survived
4 2006 Urosepsis 16 Staph C- Fem. (3) Survived
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Changes tested

• Dedicated cart

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Changes tested

• Withdrawal of other products

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Reminders...

• Technique

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Patient Perspective

• Results are posted

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Lessons Learned

• Small changes can bring big results
• The maintenance bundle has to be implemented as
  soon as possible

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Remerciements

• Thanks to the fantastic and hard working CSSSNL
  ICU quality team.

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About the Canadian ICU Collaborative
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Benefits of Participating

• Faster learning and quicker gains

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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!

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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

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Collaborative Resources

• To Enroll
• http//www.saferhealthcarenow.ca/Default.aspx?fol
  derId104contentId420
• About the ICU Collaborative
• http//www.improvementassociates.com/dnn/Default.
  aspx?tabid190
• About Breakthrough Series Collaboratives
  (general) http//www.ihi.org/IHI/Results/WhitePape
  rs/TheBreakthroughSeriesIHIsCollaborativeModelforA
  chieving20BreakthroughImprovement.htm

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Questions
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Contacts

• Bruce Harries, Collaborative Director
• bharries_at_telus.net