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  • 1. Disclosure  No Disclosures
  • 2. SUTTER ROSEVILLE MEDICAL CENTER Roseville California 315 Bed Acute Care, Community Based, Not For Profit Hospital, Includes:32 Critical Care Beds, 16 Bed NICU, 55 Bed Rehabilitation Unit, 30 Bed Extended Vent Unit, 13-07-2012 Free template from www.brainybetty.com 31 Bed Emergency Department (77,000 Visits) Level II Trauma Center 3
  • 3. Make  Safe   Speak  Up  for   Choices   Pa,ent  Safety  Spread  Safe   Design  Safe   Prac,ces   Care  Processes  
  • 4. Patient Safety Culture of Patient Safety  Preventing harm to   The way we think, talk patients about, act/react, prevent, and learn about harm to patients
  • 5.   Reduced catheter dwell time (7-14 days)  Requires physician placement  Increased patient discomfort  Dressing/securement challenges
  • 6.   11 CLABSIs in 2005  Decline in patient satisfaction  Decline in IV team productivity  Decline in FTEs/IV team  Inpatient IV Team combined with Outpatient Infusion Clinic
  • 7. Bundle Descriptors 2005Average Monthly PICC Volume 60 PICC Volume 767 Insertion Success Rate 92%Interventional Radiology Rate 8% Maximum Barrier PICC team only Insertion Site Antecubital Technique Traditional/Modified Seldinger Dressing 24 hour pressure gauze dressing then weekly Skin Preparation Alchocol/Betadine Protective disk with CHG Inconsistent Line Securement device Inconsistent Connector Positive Pressure Connector Flushing Protocol Normal Saline followed by Heparin (positive pressure flush) RN Training Annual In-Service Day Line Monitoring Completed q week with dressing change
  • 8. Prior: Current:2005: Primarily a peripheral Current: Advanced vascularIV team. access team.2005: 7A-7P coverage Current: 7A-11:30Pwith one IV nurse coverage with 4-5 PICC nurses2005: line of choice,peripheral IV and Centrally Current: line of choice PICC,Inserted Central Catheters and peripheral IV. 40%(CICC). decrease in CICCs.CLABSI = 11 CLABSI rate of Zero.
  • 9. Set a standard of practice for choosing the….. Right Right Line Patient Right Right Diagnosis Therapy 11
  • 10.   Enhanced Flow Rates (1000ml.hr.)  Hemodynamic Monitoring  Power Injection (up to 5ml/sec.)  Dual and Triple Lumen  Larger lumen sizes- up to 17 gauge  Santolucito, J.B. (2007). Role of Peripherally Inserted Catheters in the Treatment of the Critically-ill. Journal of Vascular Access Devices, 12(4), 208-217.
  • 11. 1 Santolucito, J.B. (2007). Role of Peripherally Inserted Catheters in the Treatment of the Critically-ill. Journal of Vascular Access Devices, 12(4), 208-217.
  • 12. Patient Practice Interrelationship CR-BSI Product Source: D.Macklin Technology and Practice: Collaboration for successful positive patient outcomes Infection Control Today Sept 2007. http://www.iceinstitute.com/ education.html
  • 13.   CDC, SHEA, & IHI Recommendations  Research  Impact both extraluminal catheter tract, and intraluminal fluid pathway  New product technology  Minimal bedside change  Product ease of use
  • 14.          Inser1on                Maintenance   Specialized  nurse  team   relied  on  expanded  bundle   IHI Central Line Bundle to  perfect  prac1ce   Maximal   Op,mal   Hand   Chlorhexidine   Daily   Barrier   Catheter  Site  Hygiene   An,sepsis   Monitoring   Precau,ons   Selec,on   SRMC Central Line Bundle Change  from   Maximal   IV  Connector    Ultrasound   CL  Kit   Posi,ve   Flushing   Daily   Barrier   Septum   Guided   Revision   Pressure   Protocols   Monitoring   Precau,ons   Disinfec,on   Connector  Aids   Limits  provider-­‐ Expanded  to   Neutral   Vigilant   Rou1ne  8   Ongoing  appropriate   to-­‐pa1ent   include   connector  system   cleaning  of   hourly,  10ml   evalua1on  venous   transmission   Chloraprep®,   prevents  line   septum  and   saline  flush   of  line  loca1on   through  use  of   Statlock®,   blood-­‐reflux,   change  aEer   necessity   glove,  gown,   Biopatch®   reducing  colony   each  blood   mask,  drape,  etc   opportunity   draw  
  • 15. Interventions and Rationale
  • 16. Intervention  Maximum barrier precautions, including addition of full body drape for all central line insertions Rationale  CDC recommends full barrier precautions with CVC insertion: cap, mask, sterile gown, drape to fully cover patient.
  • 17. Kit Contents Bouffant Cap, Mask, Gown, Alcohol swab sticks, CHG skin prep,CHG containing sponge,O.R. Towel, and Drapes.
  • 18. Rationale   Normal skin bacteria counts   Subclavian/jugular 10,000 cfu/cm2   Anticubital fossa 10 cfu/ cm2   Evidence has demonstrated increased safety Intervention  All PICCs placed by   Recommended by ultrasound guidance/   Agency for Healthcare basilic vein, upper arm Research Quality vein of choice   American College of Emergency Physicians
  • 19.   Application of ECG placement/confirmation performedduring insertion:  Eliminates time previously spent waiting for X-rayconfirmation readings  Allows immediate release of the line/time savings  Eliminates patient exposure to radiation/costs  Saves time required for tip repositioning ofmalpositioned tips found after the end of the procedure
  • 20. Rationale   Alcoholic Chlorhexidine Swab Sticks and Chlorhexidine-containing sponge dressing around catheter at the insertion site reduces colonization   Supports current weekly dressing change practice Intervention   Minimized the impact on  Central line dressing kit revised to the bedside nurse include Chlorhexidine-containing sponge and chlorhexidine swabs in each kit  Securement device added by PICC Nurse
  • 21. Kit ContentsMask, Cap, Gloves, Alcohol swabs, Alcoholic Chlorhexidine SwabSticks, Chlorhexidine-Containing Sponge, Tape Measure, 4X4’s, Dressing, Tape, Skin Protectant, and Drape.
  • 22. Rationale   Supports Successful Septum Disinfection   Minimal priming volume and no dead space   Eliminates blood reflux in lines   No clamping required Intervention   Saline Flush only  Zero Fluid Displacement Connector for all central lines
  • 23. Rationale   SHEA,IDSA,CDC, recommends cleaning with an alcoholic chlorhexidine preparation or 70% alcohol prior to each access.   Rapid action time, kills on contact. Kills bacteria by Intervention denaturing proteins.  Cleanse IV connector   Vigorously scrub threads threads/septum with 70% and septum of isopropyl alcohol or alcoholic needleless connector CHG for 10-15 seconds prior to EVERY access. (squeeze an orange). Apply friction and scrub!!!
  • 24.   Scrub the needleless connector with an alcohol prep for 15 seconds using friction, as if you were juicing an orange, before each access.  Purpose: Time + Friction= Disinfection
  • 25. Rationale   Effective cleaning of intraluminal surface removes fibrin   Minimizes bacterial opportunity for adherence Intervention   Prevents mixing of  Flush all CVC lumens incompatible (except implanted port medications and dialysis) with 10 ml normal saline every 8 hours as needed, utilizing a push-pause technique
  • 26. Intervention  Daily monitoring of ALL Central lines by PICC team Rationale  Continuous monitoring of practice decreases complications and increases compliance with bundle
  • 27. Data Collection Tool White Board  White board trackspatients with CVCs:type of line andinsertion site.  Data CollectionTool: tracks allpatients with CVCs,type of line, site ofinsertion, dressingchange, and possiblecomplications.
  • 28. Bundle 2005 2006 2007 2008 2009 2010 2011 Descriptors Average Monthly 60 131 189 187 159 160 158 PICC Volume Yearly PICC 767 1570 2266 2243 1904 1929 1898 VolumeInsertion Success 92% 98% 98% Rate Interventional 8% 2% 1.5% 1% Radiology RateMaximum Barrier PICC team only All central lines All central lines Insertion Site Antecubital Upper Arm, Basilic Vein Upper Arm, Basilic Vein (preferred) Traditional/Modified Technique 100% Ultrasound Guided 100% Ultrasound Guided Seldinger 24 hour pressure No pressure dressing No pressure dressing (exception excessive Dressing gauze dressing then (exception excessive bleeding) bleeding) Weekly dressing change weekly Weekly dressing changeSkin Preparation Alchocol/Betadine Chlorhexidine Chlorhexidine Protective disk Inconsistent Consistent Consistent with CHGLine Securement Inconsistent Consistent Consistent device Positive Pressure Connector Neutral Connector Neutral Connector Connector Normal Saline Flush 10ml NS every 8 hours followed by Heparin Flush 10ml NS every 8 hours and PRN useFlushing Protocol and PRN use (push/pause (positive pressure (push/pause technique) technique) flush) One-on-One Training at the One-on-One Training ,Vasc. Access Class,, RN Training Annual In-Service Day bedside housewide ongoing education Completed q week Completed daily during site Line Monitoring Completed daily during site checks. with dressing change checks.
  • 29.   Specialized PICC Teams can reduce the risk of CLABSIs  PICC Teams used as an improvement strategy to reduce CLABSIs  PICC Teams can lead to decreased infusion–related complications  PICC Teams can improve patient care outcomes  PICC Teams can increase patient satisfaction  Clin Infect Dis. 2011 May;52(9):e162-193. Epub 2011 Apr.1  Infect Control Hosp Epidemiol. 2008 Oct;29 Suppl.1:S22-30.  Joint Commission Resources, May 2012. http://www.PreventingCLABSIs.pdf.
  • 30. DialysisCLABSI indicated in graph below was inserted and maintained by contractedagency that did not follow Sutter Roseville Medical Center policies or bundle.
  • 31. Nurse Physician CLABSI PICC Team
  • 32. Determined…Relentless…Tenacious