HEN 2.0 CLABSI WEBINAR NAILING CLABSI PREVENTION! February 11, :00 a.m. 12:30 p.m. CT

Transcription

1 HEN 2.0 CLABSI WEBINAR NAILING CLABSI PREVENTION! February 11, :00 a.m. 12:30 p.m. CT 1

2 WELCOME AND INTRODUCTIONS Kimberly King, Program Specialist, HRET 11:00 11:05 2

3 WEBINAR PLATFORM QUICK REFERENCE Mute your computer audio Download today s slides and resources 3

4 ADDITIONAL REMINDERS Quality of video and audio (if listening through your computer) depends on your internet connection To maximize the size of any one pod, simply press the four-way arrow icon in the top right corner 4

5 OBJECTIVES FOR TODAY Explore recommended and emerging central line maintenance strategies. Speakers from Kern Medical Center from Bakersfield, California will describe their interventions to reduce CLABSI, specifically focusing on the maintenance bundle. Explore what will keep CLABSI prevention efforts going. Bust myths and uncover hardwiring realities. 5

6 HEN DATA UPDATE Rich Rodriguez, Data Analyst, HRET 11:05 11:10 6

7 CLABSI HEN 1.0 SUCCESSES 7

8 CURRENT HEN 2.0 CLABSI SUBMISSION RATES 79% of eligible facilities reported their CLABSI rates from All Inpatient locations 78% of eligible facilities reported ICU rates Keep the data coming! 8

9 CLABSI EVALUATION MEASURES 9

10 CLABSI EVALUATION MEASURES 10

11 CLABSI EVALUATION MEASURES

12 CLABSI PROCESS MEASURES

13 CLABSI PROCESS MEASURES

14 CLABSI PROCESS MEASURES

15 CLABSI PROCESS MEASURES

16 Central line maintenance It s not glam but got to nail it! Cheryl Ruble, Improvement Advisor, Cynosure Health 11:10 11:25 16

17 CLABSI 46% decrease between 2008 & 2013! National And State Healthcare Associated Infections Progress Report CDC, Jan

18 Your Plan CLABSI Rate Time

19 2014 CLABSI Definition changes 19

20 CLABSI Rate Time

21 CLABSI Prevention Maintenance bundle 21

22 CLABSI Prevention Maintenance bundle 22

23 Maintenance Bundle Use sterile, transparent, semipermeable dressing to cover the catheter site Replace administration tubing at intervals of less than 96 hours Establish and implement facility guidelines for intra-venous fluid administration bag changes. Scrub the hub (15 seconds) Grady NP, Alexander M, Burns LA, Dellinger P, Graland J, Heard SO, et al. Guidelines for the prevention of intravascular catheters-related infections, Retrieved at: CDC Guidelines

24 Nailing the Maintenance Bundle? Go look! Audit 5 patients with central lines 1. Dressing per standard 2. Dressing timely 3. Administration of tubing is current and labeled? 4. Intra-venous fluid current and labeled? 24

25 Beyond the Bundle additional strategies to try: Use of chlorhexidine (CHG) containing sponge dressings CHG bathing Non-suture securement device Antiseptic- or antimicrobialimpregnated central venous catheters (CVCs) for adult patients Involve patient and families in infection prevention Waltz JM, Ellison RT, Mack DA, Flaherty HM, McIllwaine JK, Whyte KG, Landry KE, Baker SP Heard SO, CCOC Research Group. The bundle Plus : the effect of multidisciplinary team approach to eradicate central line-associated bloodstream infections. Anesth Analg Oct 21. Entesari-Tatafi D, Orford N, Bailey MJ, Chonghaile MNI, Lamb-Jenkins J, Athan E. (2015). Effectiveness of a care bundle to reduce central line-associated bloodstream 25 infections. Med J Aust, 202(5): Consider patient allergies

26 INVITE PATIENTS AND FAMILIES TOO Educate using Teach Back on central line use: Purpose Duration of use Importance of prompt removal Steps being taken to prevent infection Invite patients and families to: Remind health care providers to wash their hands Ask each day if the central line continues to be necessary 26

27 RESOURCES HRET HEN Infections LISTSERV. Sign up at HRET HEN CLABSI Resources and Change Package 27

28 CASE STUDY: HOSPITAL STORY Kern Medical 11:25 11:40 28

29 KERN MEDICAL, BAKERSFIELD, CA Kristi Wood, RN, BSN, CIC, Infection Control Coordinator Dianne McConnehey BSBA, RNC, CPHQ, Director of Quality 29

30 ABOUT US County owned/operated since bed, acute care, safety net hospital Level 2 trauma center Level 3 NICU Academic teaching facility (113 Residents) Affiliated with UCLA specializing in: Emergency Medicine Internal Medicine Surgery Family Practice Obstetrics and Gynecology Psychiatry/Child/Adolescent/Addiction Serving an area of over 750,000 square miles 11,889 inpatient admissions 3,180 deliveries 43,361 emergency visits 2,422 trauma activations 166,321 outpatient visits 30

31 TESTS OF CHANGE & WHAT WE LEARNED Collaborative participation What works for other hospitals? Will it work for us? House wide education of nursing and medical staff Education specific to different roles in CLABSI prevention Implemented CDC and IHI CLABSI Bundle Medical necessity, revised order sets Audits Cleansing caps (alcohol-impregnated) eliminated need to scrub the hub What if a cap isn t in place and a port needs to be accessed? Daily CHG bathing Take the opportunity to educate on skin care Process to identify all lines inserted and ability to track Checklist completed, compliance with CLIP bundle ED Team Line Maintenance ED Team ICU Team 31

32 TESTS OF CHANGE & WHAT WE LEARNED Standardized central line carts Not all areas need carts and not all carts will need the same items Vascular access service - PICC Team Off hours: what then? Central line checklist Forms can be tricky Implemented hard stop for CLIP bundle compliance Daily feedback and re-educate, reeducate (Nursing-RN, LVN, NA & physicians) Identification of emergently placed line - red and green stickers Securement device for IJs OR Team Vascular Assess RN 32

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34 BARRIERS AND HOW WE RESOLVED THEM Identifying when central lines were inserted X-ray for line placement & reconciliation Emergent insertions and ED Red/green Stickers Femoral lines and avoiding their use Education and nurses as patient advocates Struggle with checklist completion and getting the modifications on the checklist right Space Issues for Central Line Carts and Stocking Nurses Stations Collecting denominator data Education and Reinforcement 34

35 KERN MEDICAL S 5 YEAR JOURNEY 35

36 KERN MEDICAL QUARTERLY CLABSI RATES Last CLABSI in NICU 10/7/ CLABSI in ICU Patient 6/2/15 2/27/14 6/1/15 16 months no CLABSI

37 ADVICE FOR OTHERS Buy in of leadership Nursing champions for units for reinforcement of bundle Incorporate CLABSI education into orientation Medical staff, resident, nursing Re-educate often Make sure you include the physician s residents and medical students Rapid cycle improvement process Short trials with feedback in real time Don t get discouraged by the numbers 37

38 MEASURES WHAT & HOW CLIP form submission Bundle compliance CLABSI Rates Infection control surveillance Data shared with team and organization Celebration of hospital-wide for improvement in CLABSI rate 38

39 OUR TEAM 39

40 WRAP UP AND NEXT STEPS Change is possible Once you achieve zero, don t stop Kern Medical next steps: reinforcement, re-education and continued focus on keeping our patients safe Contact: Dianne McConnehey, BSBA, RNC, CPHQ mcconned@kernmedctr.com Kristi Wood, RN, CIC or woodkr@kernmedctr.com 40

41 Hardwiring a Reliable Process for Reproducible Results Maryanne Whitney, Improvement Advisor, Cynosure Health 11:40-12:00 41

42 OBJECTIVES Bust the MYTHS surrounding reliability. Identify key elements for effective, reliable maintenance bundle for central lines. Explore new ideas to incorporate in your efforts to reduce CLABSI.

43 Reliability What does it mean if something is reliable? Think of a process or service you see as reliable. How do you know it is reliable? What makes it reliable?

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45 IS YOUR CENTRAL LINE INSERTION PROCESS RELIABLE? WHY?

46 Hard work and vigilance are all you need Education and training will fix it- more will make it better MYTHS Changing the process alone will change the outcome Changing the structure alone will change the outcome

47 DESIGN LEVELS FOR RELIABILITY Level 3: Design of integrated systems and high reliability organizations Level 2: Design informed by reliability science and research in human factors Level 1: Intent, vigilance and hard work

48 CHARACTERISTICS OF HIGH FAILURE PROCESSES No articulated common process Emphasis on training and reminders

49 Characteristics of Low Failure Processes Processes intentionally designed with tools and concepts to prevent or mitigate human errors (human factors engineering)

50 CVC MAINTENANCE BUNDLE Daily assessment for line necessity Sterile transparent dressing changed (q 7 days or less) IV tubing changes (96 hour or less) IV fluid changes Scrub the hub (15 seconds)

51 BE ALERT Normalization of deviance The normalization of deviance can be defined as: a gradual process in which an unacceptable practice or standards become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization Dr. Diane Vaughan

52 Attaining Reliability Three Step Process 1. Prevent Failure 2. Identify and Mitigate Failure that occurs 3. Redesign to Eliminate Critical Failures that have occurred

53 STEP 1: PREVENT FAILURE Eliminate failure option Basic standardization: Common equipment brands Standard order sheets Guidelines Memory aids, such as checklists Feedback mechanisms Compliance with standards- don t assume they know

54 MYTHS 1 &2 The evidence is in: Hard work & vigilance along with education & training is not enough!

55 PREVENTION TECHNIQUES Central line dressing kits with all necessary pieces IV team- perform and track dressing changes EHR reminders for dressing changes and IV tubing changes

56 STEP 2: IDENTIFY FAILURE AND MITIGATE Independent redundant checks Focus on catching or identifying instances when the standardized approach is not used Correct and minimize negative effect

57 Reminders and Visual Clues

58 Differentiation Reduce confusion when contents, names or numbers are similar Color coding Identify items in easily distinguishable ways

59 Constraints Restrict or limit the performance of certain actions Sizing parts differently

60 Affordances Provide clear visual or other sensory clues that lead the user to use a product or tool correctly, or perform the correct action

61 How do we mitigate failure in the bundle? PICC team for central line dressing changes- standard process. Empower the staff to stop the line if sterile technique is breached. Timely process to address lines placed emergently. Charge nurse rounds review line necessity. Targeted leadership rounds: Does your patient have a central line? EHR prompts and alerts.

62 MYTHS 3 & 4 Together: Process & structural changes drive outcome

63 Step 3: Redesign 1. Root Cause Analyses What did happen? 2. Failure Modes and Effects Analysis What might happen? 3. Learning Loop Performance feedback

64 Redesign Central Line Maintenance Engineered for success Alcohol impregnated caps CHG bathing Securement devices EHR reminders and reports

65 HOW ABOUT YOU? Consider that key step in your project that is prone to failure. How can you correct it in real time? How might you redesign it?

66 Easy to do the Right Thing Make it hard to do the wrong Make thing it hard to the wrong thing

67 HARDWIRING RELIABILITY Hard work and vigilance alone will never create reliable systems. o Work harder or focus are NOT the principles of reliable system design. Education and training are required, but never sufficient. Structure + Process = Outcome Make it hard to do the wrong thing. Make it easy to do the right thing.

68 QUESTIONS

69 BRING IT HOME Kimberly King, Program Specialist, HRET 12:00 12:15 69

70 PHYSICIAN LEADER ACTION ITEMS What are you going to do by next Tuesday? Examine current state of our CLABSI maintenance bundle efforts. Observe 5 central line dressings for timeliness and procedure. What are you going to do in the next month? Share the CLABSI data with physicians and the leadership. Support unit based team in redesigning the central line dressing process and equipment. 70

71 UNIT-BASED TEAM ACTION ITEMS What are you going to do by next Tuesday? Engage leadership to explore CHG bathing and alcohol impregnated caps. Engage frontline staff member to plan and test patient CHG bathing. Engage frontline staff to trial alcohol impregnated caps. Engage frontline staff to evaluate the current state of central line dressing changes and the equipment. What are you going to do in the next month? Evaluate the PDSA cycles done with the patient CHG bathing education, adapt, adopt, and spread. Redesign central line dressing change process and equipment to enhance reliability. 71

72 HOSPITAL LEADERS ACTION ITEMS What are you going to do by next Tuesday? Review your organization s CLABSI rates. What are you going to do in the next month? Review CLABSI rates by department and provider medical to identify opportunities. Work with nursing departments to conduct a gap analysis to identify evidence based practices that are are missing from the CLABSI maintenance bundle and prioritize adoption of targeted interventions. 72

73 PFE LEADS ACTION ITEMS What are you going to do by next Tuesday? Evaluate current central line education materials. What are you going to do in the next month? Interview three patients who have a central line to evaluate their understanding of how best to prevent CLABSI. Share patient interview results with the appropriate provider and department. 73

74 THANK YOU! Find more information on our website: Questions/Comments: 74