1. +
Quality Improvement: IV Tubing
Toledo Hospital – Urology, Nephrology, & Vascular
Erin Bedell, Katelynn Butler, Sarah Dinger,
Jacquelyn Gawle, Thomas Meridieth, Cait
Zimmel
2. +
Research Outline
Population: 39 beds out of 40
Compliance: Low
Problem: Noncompliance & Lack of Supplies
Consequences: Financial Burden & Infection Risk
3. +
Pre-Data Collection Questionnaire
IV Tubing Change Primary
66% - 96 hours
22% - 96 hours and 24 hours intermittent
11% - 24-72 hours
Secondary
55% - 24 hours
33% - 96 continuous/24 intermittent
11% - after infusion complete
Swab Caps to Each Port 100% - Yes
Changing Swab Caps 44% - every time used
22% - as needed
34% - every 24 hours
Primary Solution 100% - change every 24 hours
Primary Solution Label 100% - said blue label
22% - admitted to forgetting to label every time
67% - answered yes that they use them every time
and a blue label
11% - blue label if it is stocked
4. +
Pre-Data Collection Questionnaire
Primary Tubing Label 34% - admitted to forgetting; knew white for 96 hrs.
and pink for 24 hrs.
22% - white for 96 hrs. & pink for 24 hrs.
44% - white
Secondary Tubing Label 22% - admitted to forgetting; answered pink
22% - admitted to forgetting; use pink for 24 hour
intermittent and white for 96 hour continuous
56% - pink and change every 24 hours
Labeling Improvement 44% - “none”
11% - “none, but needs stocked”
11% - “check daily”
33% - “needs to be stocked”
Suggestions 44% - “N/A” or “none”
56% - “stock labels”
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IV Tubing Data: 6 North TTH
11%
89%
IV Catheter Dressing Labeling on 6N
Labeled Correctly
Labeled Incorrectly
6. +
IV Tubing Data: 6 North TTH
37%
63%
Primary Tubing Labeling on 6N
Labeled Correctly
Labeled Incorrectly
7. +
IV Tubing Data: 6 North TTH
17%
83%
Secondary Tubing Labeling on 6N
Labeled Correctly
Labeled Incorrectly
8. +
IV Tubing Data: 6 North TTH
56%
44%
Fluid Bag Labeling on 6N
Labeled Correctly
Labeled Incorrectly
9. +
IV Tubing Data: 6 Northeast TTH
12%
88%
IV Catheter Dressing Labeling on 6NE
Labeled Correctly
Labeled Incorrectly
10. +
IV Tubing Data: 6 Northeast TTH
87%
13%
Primary Tubing Labeling on 6NE
Labeled Correctly
Labeled Incorrectly
11. +
IV Tubing Data: 6 Northeast TTH
100%
Secondary Tubing Labeling on 6NE
Labeled Correctly
Labeled Incorrectly
12. +
IV Tubing Data: 6 Northeast TTH
75%
25%
Fluid Bag Labeling on 6NE
Labeled Correctly
Labeled Incorrectly
13. +
IV Tubing Data: 6 South TTH
44%
56%
IV Catheter Dressing Labeling on 6S
Labeled Correctly
Labeled Incorrectly
14. +
IV Tubing Data: 6 South TTH
36%
64%
Primary Tubing Labeling on 6S
Labeled Correctly
Labeled Incorrectly
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IV Tubing Data: 6 South TTH
71%
29%
Secondary Tubing Labeling on 6S
Labeled Correctly
Labeled Incorrectly
16. +
IV Tubing Data: 6 South TTH
19%
81%
Fluid Bag Labeling on 6S
Labeled Correctly
Labeled Incorrectly
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Follow-Up Questionnaire
Question 2: “What would help you to remember to label your IV tubing?”
Reminder sign
22%
Sign for 96 vs.
24hr sticker
0%
Sticker on
pump
22%
Sticker on
tubing
45%
Other
11%
27. +
Root Cause Analysis
Nursing Noncompliance
Lack of Supplies on the Units
Low Nursing Priority
Lack of Auditing
28. +
Financial Impact from Primary IV
Sets
Cost of Primary Tubing is $8.37 per Tubing Set (based on
MedShop.com)
15 total primary tubing sets in noncompliance on 6th floor
30 total sets of primary tubing at $8.37/set, on the floor costing
$251.10
15 additional sets of primary tubing at $8.37/set, to replace
noncompliant tubing costing $125.55
Total cost of primary tubing per day on the 6th floor is $376.65
With 100% compliance, tubing would cost $91,651.50 in one year
With the Primary Tubing Compliance at 50%, over one year, the
additional cost to replace noncompliant tubing is $45,825.75
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Financial Impact from Secondary IV
Sets
Cost of Secondary Tubing is $2.13 per Tubing Set (based on
LetMedco.com)
7 total secondary tubing sets in noncompliance on 6th floor
15 total sets of secondary tubing at $2.13/set, on the floor costing
$31.95
7 additional sets of secondary tubing at $2.13/set, to replace
noncompliant tubing costing $14.91
Total cost of secondary tubing per day on the 6th floor is $46.86
With 100% compliance, tubing would cost $11,661.75 in one year
With the Secondary Tubing Compliance at 53%, over one year,
the additional cost to replace noncompliant tubing is $5,442.15
30. +
Financial Impact for Potential
CLABSI’s
$16,350/CLABSI based on research (Ramirez, 2012)
For example, the floor has one CLABSI event in a given calendar
year
Cost: $16,350.00 for CLABSI event
Additional cost: $45,825.75 for noncompliant primary tubing
Additional cost: $5,442.15 for noncompliant secondary tubing
Potential additional cost from noncompliant IV tubing sets:
$67,617.90 for one CLABSI event and noncompliant IV tubing in
one calendar year
31. +
National QI Initiatives
Five Evidence Based Steps to Prevent CLABSI
Use appropriate hand hygiene
Use chlorhexidine for skin preparation
Use full-barrier precaution during central venous catheter insertion
Avoid using the femoral vein for catheters in adult patients
Remove unnecessary catheters
IV Tubing Recommendation for use
Replace tubing used to infuse blood or blood products or lipid-
containing solutions at least every 24 hours
Replace tubing used to infuse Propofol every 6-12 hours
Replace tubing used to infuse solutions containing dextrose and amino
acids without lipids every 72 hours
Replace other tubing every 96 hours
Agency for Healthcare Research & Quality, 2013
32. + Central Line-Associated Bloodstream
Infections Among Critically Ill Patients in the
Era of Bundle Care
Level 4 - Systematic Review and Cohort Study
Limitations (Lin K-Y, et. al., 2015)
These findings were different from the NHSN report and other
studies
Considerable overlap between the definition of CLABSI and CRBSI
They assume that diagnosis of CLABSI often overestimates the true
number of infections that are attributable to central lines
Sample size was limited to a single medical center
The definition of CLABSI had changed since 2011
Compliance rate of intervention bundle and checklist was nearly
95%, so the findings may not be comparable to those in intuitions
whose compliance rates are substantially different from theirs
33. +
Disinfection of Needleless Hubs: Clinical
Evidence Systematic Review
Level 1 - Systematic Review of Current Literature
Limitations (Flynn and Moureau, 2015)
Studies spanned from 1977-2014
Lack of high quality research
Absence of high quality RCT
Low level evidence base
Lack of randomization – unintentional bias
34. +
Swab Cap Articles
“Reducing Bloodstream Infection
Risk in Central and Peripheral
Intravenous Lines: Initial Data on
Passive Intravenous Connector
Disinfection” (DeVries et. al.,
2014)
Provides information on
Bloodstream Infection prevention
with the use of swabcaps on all
ports as an intervention. As a result
the BSI’s decreased in both central
and peripheral lines overall by 45%.
This was an observational study.
“Impact of universal
disinfectant cap
implementation on central
line- associated bloodstream
infections” (Merrill, K. C. et. al.,
2014)
Provides information on central line
associated blood stream infections
resulting in length of stay, cost,
patient morbidity and mortality. This
quasi- experimental study
determined the placement of
disinfectant caps decreased
infection rates by >40% and saved
approximately $300,000 per year.
Limitations of this study include
ongoing education to nurses on the
prevention of CLABSI while the
study was in progress.
35. +
Change IV Tubing Less Often
Not backed by evidence
Cost Australia $1 billion each year
Free up nurses time for patient care
Save 2 million nursing hours
3 year study of 6,500 patients
Comparing 4 and 7 day tubing changes
Largest National Health and Medical Research Council funded
nursing project and research grants awarded
Australian Nursing Journal, 2016
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Change Theory
Kurt Lewin’s Force-Field Model (Finkelman, 2016)
Improves the Change Process
Clarifies Balance of Power
Identifies the Key Players
Identifies Opponents and Allies
Identifies How to Influence Each Other
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Recommendations
Reinforce 60 second
assessment
Ensure adequate stock is
ordered
Notify immediately if labels are
not stocked
Prompt when scanning IV fluids
Care alert notification
Verbalize IV bag and label
changes in bedside report (IHI,
2016)
Morning huddle discussion (IHI,
2016)
Nurse leaders audit unit
(O’Grady, 2011)
Mandatory in-service on policy
and procedure (O’Grady, 2011)
Additional research to support
need to change tubing every 24-
96 hours (O’ Grady, 2011)
Internal Evidence
& Clinical Expertise
Evidence Based
38. +
Hypothesis
Using Lewin’s Change Theory and our recommendations, the
unit will maintain their low CLABSI rate and ensure patient
safety, as well as save their unit money by wasting less
equipment through compliant labeling of solutions and tubing
and keeping accurate records through charting.
39. + Resources
(2011). Change IV tubing less often. Australian Nursing Journal, 19(4), 22-221p
(2013). Agency for Healthcare Research & Quality. Retrieved April 16, 2016, from
http://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools/clabsitoolsap3.html
DeVries, M., Mancos, P. S., & Valentine, M. J. (2014). Reducing Bloodstream Infection Risk in Central and Peripheral
Intravenous Lines: Initial Data on Passive Intravenous Connector Disinfection. Journal Of The Association For Vascular
Access, 19(2), 87-93 7p. doi:10.1016/j.java.2014.02.002
Finkelman, A. (2016). Leadership and management for nurses: core competencies for quality care. 3rd Ed. Pearson
Education, Inc: New York.
Flynn, J. & Moureau, N. L. (2015). Disinfection of needless hubs: clinical evidence systematic review. Nursing Research
and Practice 2015,796762.doi:10.1155/2015/796762
Lin K-Y, et. Al. (2015). Central line-associated bloodstream infections among critically-ill patients in the era of bundle care,
Journal of Microbiology, Immunology and Infection. http://dx.doi.ord/10.1016/j.jmii.2015.07.001
Merrill, K. C., Sumner, S., Linford, L., Taylor, C., & Macintosh, C. (2014). Impact of universal disinfectant cap implementation
on central line- associated bloodstream infections. American Journal of Infection Control, 42, 1274-1277.
O'Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., . . . Saint, S. (2011). Guidelines for the
prevention of intravascular catheter related infections. American Journal of Infection Control, 39(4), S1-S26.
Ramirez, C., Lee, A. M., & Welch, K. (2012). Central Venous Catheter Protective Connector Caps Reduce Intraluminal
Catheter-Related Infection. Journal Of The Association For Vascular Access, 17(4), 210-213 4p.
doi:10.1016/j.java.2012.10.00
Relay Safety Reports at Shift Changes. (n.d.). Retrieved April 20, 2016, from Institute for Health Care Improvement website:
http://www.ihi.org/resources/pages/changes/developacultureofsafety.aspx
Began our project by asking the staff to answer a questionnaire about IV tubing protocols and any recommendations they may have.
How often (per protocol) should you change your tubing?
Do you use a swab cap on each port?
How often do you change your swab caps?
How long can a bag of primary solution hang before you have to change it?
Do you label on your primary solution every time? What color do you use?
Do you place a label on your tubing every time? What color label for primary?
What color for secondary?
What part of labeling or hanging IV solution/medications do you think could use improvement?
Do you have any suggestions about how to improve labeling or swab cap usage?
The North Wing on the 6th Floor at Promedica Toledo Hospital had 9 IV Catheter Dressings on the wing. Of the 9 dressings, only 1 was in compliance with the proper date, time, and initial of the RN. That leaves the wing in 11% compliance for their IV Dressings.
The North Wing on the 6th Floor at Promedica Toledo Hospital had 8 IV Primary Administration sets on the wing. Of the 8 Primary sets, only 3 were in compliance with the proper date, time, and initial of the RN. That leaves the wing in 37% compliance for their Primary IV sets. However, the Primary Tubing sets on the wing were in 100% compliance with orange caps on the ports.
The North Wing on the 6th Floor at Promedica Toledo Hospital had 6 IV Secondary Administration sets on the wing. Of the 6 Secondary sets, only 1 was in compliance with the proper date, time, and initial of the RN. That leaves the wing in 17% compliance for their Secondary IV sets.
The North Wing on the 6th Floor at Promedica Toledo Hospital had 9 IV Fluid Bags on the wing. Of the 9 IV Fluid Bags, only 5 were in compliance with the proper date, time, identification of the fluid, and initial of the RN. That leaves the wing in 56% compliance for their IV Fluid Bags. However, one of the bags that was labeled properly, happened to be expired.
The Northeast Wing on the 6th Floor at Promedica Toledo Hospital had 8 IV Catheter Dressings on the wing. Of the 8 dressings, only 1 was in compliance with the proper date, time, and initial of the RN. That leaves the wing in 12% compliance for their IV Dressings.
The Northeast Wing on the 6th Floor at Promedica Toledo Hospital had 8 IV Primary Administration sets on the wing. Of the 8 Primary sets, only 7 were in compliance with the proper date, time, and initial of the RN. That leaves the wing in 87% compliance for their Primary IV sets. However, the Primary Tubing sets on the wing were in 75% compliance with orange caps on the ports.
The Northeast Wing on the 6th Floor at Promedica Toledo Hospital had 2 IV Secondary Administration sets on the wing. Of the 2 Secondary sets, all 2 were in compliance with the proper date, time, and initial of the RN. That leaves the wing in 100% compliance for their Secondary IV sets.
The Northeast Wing on the 6th Floor at Promedica Toledo Hospital had 8 IV Fluid Bags on the wing. Of the 8 IV Fluid Bags, only 6 were in compliance with the proper date, time, identification of the fluid, and initial of the RN. That leaves the wing in 75% compliance for their IV Fluid Bags.
The South Wing on the 6th Floor at Promedica Toledo Hospital had 16 IV Catheter Dressings on the wing. Of the 16 dressings, only 7 were in compliance with the proper date, time, and initial of the RN. That leaves the wing in 44% compliance for their IV Dressings.
The South Wing on the 6th Floor at Promedica Toledo Hospital had 14 IV Primary Administration sets on the wing. Of the 14 Primary sets, only 5 were in compliance with the proper date, time, and initial of the RN. That leaves the wing in 36% compliance for their Primary IV sets. However, the Primary Tubing sets on the wing were in 71% compliance with orange caps on the ports.
The South Wing on the 6th Floor at Promedica Toledo Hospital had 7 IV Secondary Administration sets on the wing. Of the 7 Secondary sets, only 5 were in compliance with the proper date, time, and initial of the RN. That leaves the wing in 71% compliance for their Secondary IV sets.
The South Wing on the 6th Floor at Promedica Toledo Hospital had 16 IV Fluid Bags on the wing. Of the 16 IV Fluid Bags, only 3 were in compliance with the proper date, time, identification of the fluid, and initial of the RN. That leaves the wing in 19% compliance for their IV Fluid Bags.
The average Dressing Label Compliance for the entire 6th Floor at Promedica Toledo Hospital was 27%. While the North wing (11%) and Northeast wing (12%) fell below the average for the floor, the South wing at 44% had the highest compliance rate on their IV dressing labels.
The average Primary Tubing Label Compliance for the entire 6th Floor at Promedica Toledo Hospital was 50%. The North wing (37%) and South wing (44%) fell below the floor average, while the Northeast wing was above average at 87%.
The average Secondary Tubing Label Compliance for the entire 6th Floor at Promedica Toledo Hospital was 53%. The North wing (17%) was the only wing below the entire floor average. While the Northeast wing (100%) and the South wing (71%) were both above the entire floor average.
The average IV Bag Label Compliance for the entire 6th Floor at Promedica Toledo Hospital was 42%. The South wing (19%) was the only wing below the floor average. While the Northeast wing (75%) and North wing (56%) were both above the average for the floor.
This graph represents how the nursing staff on the 6th floor of Toledo Hospital, on 4/13/2016, answered the question “What would help you to remember to label your IV solution bag”. The majority of staff, 34%, chose the answer “ Having central supply tape a label to the solution bags upon stocking”. The second most frequent response (33%) was “Having labels right next to the bags-on the same shelf”. The remaining total were equally distributed at 11%; a reminder sign, labels at station, and other. Other “was having labels period” .
This graph represents how the nursing staff on the 6th floor of Toledo Hospital, on 4/13/2016, answered the question “What would help you to remember to label your IV tubing?”. The majority of the staff, 45%, chose the answer “A sticker taped to the IV tubing”. The Second most frequent response was a tie between “ Having a sign on the shelf to remind you to grab a sticker near the tubing supply” (22%) and “Having a sign that reminds you what sticker to use for 96hr vs. 24hr” (22%). The remaining 11% hand wrote in “ Having the labels available”.
This graph represents how the nursing staff on the 6th floor of Toledo Hospital, on 4/13/2016, answered the question “What would help you to remember to place swab caps on each port?”. The majority of staff, (67%) chose “Keeping swab caps in a closed top container on each WOW”. The second most frequent repose was “Creating and using an IV bundle kit- including swab caps and tubing” (22%). The third most frequent response was “ Only using the flushes with the swab caps attached” (11%).
This graph represents how the nursing staff on the 6th floor of Toledo Hospital, on 4/13/2016, answered the question “Would an IV tubing/infusion bundle kit be more beneficial to facilitating care in amore timely fashion?” Majority of staff, 67%, answered yes and 33% answered no.
This graph represents how the nursing staff on the 6th floor of Toledo Hospital, on 4/13/2016, answered the question “Are there any other physical barriers besides not having the labels stocked on the floor that prevent you from labeling your solution/tubing?”. The majority, 67%, answered no. 33% answered yes; writing the following as barriers: “Want EBP proof of expiration”, “Need labels” and “ Duplicate labels, secondary and primary and bag”.
This graph represents the mean rankings of the importance of nursing task, according to staff on the 6th Floor at Toledo Hospital, on 4/3/2016. The staffs highest priority according to the questionnaire was safety (7.66), the second highest was a pain assessment (5.88), following blood sugar (5.55), a 60 second assessment (4.88), Intake and Output (4.33), Daily weights (3.55), Hourly rounding (2.77), and the lowest ranked was IV tubing at 1.33.
This is based on the information acquired from the questionnaires and the data collection in every patient room on 3/22/2016
Financial burdens occur due to waste of tubing and solutions.
Evidence is based on NQI, CDC and NIH findings and protocols.
Due to the low priority of IV tubing labeling on this unit based on the survey, there is a lack of compliance.
Also, with the new Transitioning Toledo program, the managers said they used to do chart audits on IV tubing, daily weights, etc. and now they do not have the time.
Flynn and Moureau did a systematic review to assess the current literature related to disinfection of needleless connectors to establish recommendations that promote aseptic access and reduce infection risk for the patient. The authors used Pubmed, Medline, Scopus, Ovid, jStor, CINAHL, Cochrane, Athens and ScienceDirect to gather the articles used for this review.
The authors are aware that their review has limitations. In order to find articles for this review, key terms were used to search for any article pertaining to disinfection, aseptic technique or reducing line infections from studies spanning from 1977-2014. There is a lack of high quality research available in the area of testing the cause and effect relationship between needleless connector disinfection practices and patient infection outcomes. There is also an absence of high quality RCT evidence, which limit the authors to clinical observational, cohort and laboratory studies. The evidence base for disinfection strategies is low level. With the lack of randomization, there is a risk of unintentional bias. These studies need randomized controls in order to rigorously evaluate the efficacy of disinfection practices and antiseptic hub protectors in preventing patient infection.
Lead researcher professor Claire Rickard, of Griffith University’s Research Centre for Clinical and Community Practice Innovation, said the current practice of routine tubing changes every 3-4 days was no backed by evidence and cost Australia about $1 billion each year
Study on the prolonged use of intravenous tubing may save 2 million nursing hours per year with no threat to patient safety
3 year study of 6,500 patients at Queensland’s Gold Coast, Prince Charles, Princess Alexandra, Royal Brisbane, and Women’s and Royal Children’s hospitals will study the infection and cost benefits of less frequent changes of IV tubing
The goal is to get the driving forces, or the Allies of the unit, to dominate the resistant forces, or the Opponents of the unit by listening to their concerns, promoting the change, and hopefully creating a new attitudes, values and behaviors to put the change into practice.
Here is our idea for the unit:
Start with
Unfreezing stage: Nurse management holds a mandatory in-service on labeling tubing, solutions, and sites, as well as how they prevent CLABSI.
Then go on to the:
Moving stage: Spread the word about the problem at hand and formulate an auditing team of nurses that checks the compliance of the tubing first thing every shift and for each wing. Goal is complete compliance with labeling to avoid CLABSI and financial cost to the unit. Goal should be met in 30 days and then reevaluation can occur.
Lastly:
Refreezing stage: After 30 days, find out whether the auditing is being done and that compliance is being reached by refreezing and evaluating the protocol as a whole. Make any necessary changes to the protocol and begin the unfreezing stage again.
As a group, we hypothesized that if changes were not put into place to combat these problems, the unit will suffer financially and most importantly, the unit is putting the patient’s at risk for a CLABSI infection.
With the recommendations of auditing rooms and checking the charting, we are helping the unit to maintain their low CLABSI rate and ensuring patient safety and well being. By auditing the labeling process, the unit should see some financial improvements.
