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Target Zero: Adding the protection of CHG without increasing cost


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About 3M Health Care …

About 3M Health Care
3M Health Care, one of 3M’s six major business segments, provides world-class innovative products and services to help healthcare professionals improve the practice, delivery and outcome of patient care in medical, oral care, drug delivery, food safety and health information markets. Learn more at

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  • 1. Bryn Mawr Hospital Main Line Health System Kelly Ann Zazyczny, RN, BSN ,CPNNurse Manager, Pediatrics & IV/PICC Team Patricia McCusker, RNClinical Ladder III Staff Nurse, IV/PICC Team Project Pilot: February, 2010
  • 2.  Bryn Mawr Hospital, a Philadelphia suburb community hospital and member of the Main Line Health System, is a magnet designated hospital that is licensed for 319 beds. Bryn Mawr Hospital joined the CUSP initiative in late 2009. Target Zero was our goal. We set out to achieve our goal by applying evidence based practices and critical thinking to all aspects of central line insertion and care. With a successful insertion bundle already in place, our concentration was maintenance. Maintenance bundles were initiated, daily monitoring of all lines was in place initiated place, standardized cap care and surveillance monitors were being used routinely. Wanting to provide exceptional patient care while maintaining a lean environment, we decided to add a barrier of protection to our central lines that has the potential to inhibit the growth of microbes at the insertion site; therefore, we needed to perform a product evaluation. With the participation of Infection Control and the nurse manager of the IV/PICC Team, the IV Team performed a cost and product evaluation to consider adding the Biopatch, a sterile round disc used around the catheter insertion site that contains CHG to our current dressing practice or introduce a new product the 3M CHG Securement Dressing After careful consideration, we decided to pilot Dressing. consideration the new 3M Securement Dressing.
  • 3. 30000 TOTAL COST PER YEAR 25000 20000 15000 10000 5000 0 Current Dressing with Biopatch Current Dressing  3M CHG Securement DressingNote: This does not include cost savings for nursing care hours eliminated with theomission of the 24 hour dressing change.
  • 4. Patient initials:________ MR#:_______ DOB:________ Pt. Room #:________ Insertion Date:________ Lumen size:_____ Arm used:__________ Removal Date:___________ Reason for PICC:_______________________________________ Date:_____________Area of Observation Initial Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7Please respond Yes or No.1. Routine Dressing Change?2. Initial dressing  3M CHG Tegaderm ?3. 3M CHG Tegaderm placed at 24hr mark?3. Dressing size appropriate?4. Evidence of PICC migrating?5. Edges of Dressing intact?6. Securement tapes intact?7. Insertion site occlusive?8. Insertion site visible?9. Did dressing last 7 days? If NO, Drsg changed?10. Signs and symptoms of Infection?11. Was product removed without difficulty?
  • 5.  A comprehensive pilot was initiated in the Intensive Care Unit (ICU) and Cardiac Care Unit (CCU) for two weeks. With the assistance of the 3M staff all members of the IV/PICC Team as well as ICU and CCU nursing staff were in- serviced on the placement, assessment and removal of the dressing. The stat lock was removed from our dressing practice and the 24 hour dressing was also eliminated unless needed This would provide for the CHG to remain intact for needed. the entire seven days. Every line was monitored daily by the IV Team and the findings were documented on the audit sheets. Because of the successful results in the Intensive Care Units, the pilot was implemented throughout the hospital for an additional three weeks. We gathered our data from the pilot and after careful consideration, we changed our practice t include the 3M CHG dressing as a part of our Centrall Li ti to i l d th d i t f C t Line Dressing. The dressings are monitored daily and assessments were documented in computerized documentation system.
  • 7.  With the successful completion of our pilot, we changed our practice to include the 3M CHG Securement Dressing. Dressing The new dressing was added to our central line dressing kit. Our practice was changed across our system in August, 2010 and all fi h it l are now successfully A t 2010, d ll five hospitals f ll using the 3M CHG Dressings on all central lines.  Bryn Mawr Hospital  Paoli Memorial Hospital  Bryn Mawr Rehab Hospital  Lankenau Medical Center  Riddle Memorial Hospital
  • 8.  During the 12 month period (M 09 through Feb-10) prior to implementation of the D i th th i d (Mar-09 th h F b 10) i t i l t ti f th central line maintenance bundle; 13 central line associated blood stream infections were reported over 5,177 central line days from both critical care units at the Hospital At this point 3 months of data are available post point, post- implementation. (Appendix 1a &1b). A 20 % reduction in CLABSI have been noted from the previous year. There have b Th h been zero CLABSI iin b h ICU and CCU f January, F b both d for J February and March of 2011. There was one CLABSI in non critical area in January 2011 and zero in the month of February 2011.
  • 9. Appendix 1a
  • 10. Appendix 1b
  • 11.  The stakeholders in the initial process  The CUSP Team  The IV/PICC Team  Infection Prevention Committee  The medical staff in the ICU and CCU  The nursing staff and management in the ICU and CCU. The process was driven by the IV/PICC Team with the support of management allowing us to have some extra staff to provide efficient monitoring and documentation for our pilot The pilot. process was supported by the 3M staff who made themselves available to train the nurses how to properly use the product. There was some initial concern from the nurses due to the fact that the stat lock was not being used. used They wanted the best care for their patients The nurses were not confident in the patients. securement ability of the 3M dressing and they were anxious about line dislodgement due to their perception of a lack of securement. We assured them that the IV/PICC Team would closing monitor all lines and documenting any changes. The Th CUSP committee has put CLABSI elimination as goall and the staff is very engaged in itt h t li i ti d th t ff i di preventing infections. Senior leadership’s continued support was crucial in maintaining the positive results.
  • 12.  There was an initial loss of five lines over two weeks at one of the campuses and this frustrated team members at the other sites. We realized that there were some issues with patients that had ‘weeping skin’ and that the CHG gel pad was absorbing too much liquid and losing some of the adherence. Posters showing the acceptable levels of absorption helped identify lines at risk and they were addressed quickly to avoid line dislodgement dislodgement. There was some resistance from the IV/PICC Teams at the other campuses because they did not directly experience the success of the product. The greatest challenge was the implementation of the new 3M CHG Securement Dressing across all five campuses at the same time. We should have converted one campus at a time and used the trained staff to visit the other campuses along with the 3M reps to educate and work along side of the team members. t b The new process was implemented before every staff nurse could be trained and educated on the new product. We had 3M representatives revisit all the campuses. In addition we made campuses addition, additional posters to further educate the staff and address any issues.
  • 13. ▪ GO SLOW !▪ PLAN WISELY !▪ We all know the power of CHG and the importance in targeting zero for any hospital acquired infection.▪ Ensure that all stake holders in the project are directly involved with the planning and implementation.▪ I t Integrall t the success of this initiative or any iinitiative iis th to th f thi i iti ti iti ti the creation of an engaged interdisciplinary team. Individual members must demonstrate leadership abilities and all team members must dedicate their time to institute these interventions on a short timeline.
  • 14.  We developed a dressing monitor tool to assess the central line dressing on a monthly basis. We use this surveillance tool monthly and report findings to the floors and the IV/PICC Team. If a CLABSI does occur, a drill down is down with the Infection Preventionist, Preventionist the nurse involved in the patient s care and the patient’s IV/PICC Team. The infection rates are shared monthly in all our units. Chart audits are performed monthly to monitor if the PICC line is being assessed on a daily basis and the documentation is complete. complete The results are shared with the IV/PICC Team and areas that need improvement are reviewed.
  • 15. Central Line Dressing Site Observation Tool Facility Name_______________ Date______________________ Observer Initials ____________ Unit______________________A B C D E F G H I J K L N M O TPN Dressing Blood CatheterObs Insertion infusing Dressing Clean and Dressing Dressing Present at Purulent Caps Catheter SecuredNo Bed Date Site RED pt Intact Dry Dated Expired Site Erythema Drainage Expired? Secured With: 1 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 2 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 3 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 4 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 5 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 6 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 7 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 8 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 9 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 10 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 11 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 12 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 13 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 14 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 15 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 16 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 17 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 18 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 19 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U 20 S J F P A Y N N/A Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Y N U Tool: S = subclavian; J = jugular; F = femoral; P = PICC; Modified: 3/17/2010 G = gauze; T = transparent; B = gauze and transparent See Associated Data Dictionary for Assistance: y Y = task completed; N = task not completed; U = Not Observed
  • 16. Pressure dressing was applied to outside Steri stripes applied for patients dressing for those patients the nurse was with weepy skin. concerned that oozing would occurred. gImage used for education to show Additional strip p p placed closely yproper CHG pad size in assessing under lumens. adhesion securement properties.