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
Make Safe Speak Up for Choices Pa,ent Safety Spread Safe Design Safe Prac,ces Care Processes
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
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
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
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.
Set a standard of practice for choosing the….. Right Right Line Patient Right Right Diagnosis Therapy 11
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.
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.
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
CDC, SHEA, & IHI Recommendations Research Impact both extraluminal catheter tract, and intraluminal fluid pathway New product technology Minimal bedside change Product ease of use
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
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.
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
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
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
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
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!!!
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
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
Intervention Daily monitoring of ALL Central lines by PICC team Rationale Continuous monitoring of practice decreases complications and increases compliance with bundle
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.
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.
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.
DialysisCLABSI indicated in graph below was inserted and maintained by contractedagency that did not follow Sutter Roseville Medical Center policies or bundle.