Objectives. Salem Health 11/1/2017. A Lean Journey to Reducing Central LineAssociated Bloodstream Infection (CLABSI) Rates

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1 11/1/2017 A Lean Journey to Reducing Central LineAssociated Bloodstream Infection (CLABSI) Rates Julie Koch, RN, BSN, MSN, CIC Infection Prevention Manager Objectives Describe the Lean Management System applied to Healthcare Review current literature regarding prevention of CLABSI Apply Lean Management principles to the prevention of CLABSI Measure success using NHSN criteria and Visual Management 2 Salem Health 3 1

2 What do we know about central lines? 2.27 fold increased risk for mortality 1 CLABSIs are 65-70% preventable 2 Cost of a CLABSI: $21,400 to $110, Infusion Nurses Society J Infus Nurs 2011;. 2 Umscheid, CA, Mitchell Md, Doshi, TA, et al. Infect Control Hosp Epidemiology 2011; NURSES SOCIETY. INFUSION NURSING STANDARD OF PRACTICE. J INFUS NURS 2011; 34(1S),S102 4 HAC & VBP VBP Designed to structure Medicare s payment system to reward providers for the quality of care they provide. Adjusts payments to hospitals under the IPPS (Inpatient Prospective Payment System) Measures: eg. CLABSI, C. difficille infection, elective delivery prior to 39 weeks gestation Domains with weights Clinical Care (25%) Safety (20%) Efficiency and Cost Reduction (25%) 5 5 HAC & VBP HAC Hospital-Acquired Condition Reduction Program Mandated by the Affordable Care Act Includes CLABSI, CAUTI, SSIs (Colon Surgeries & Abdominal Hysterectomies) Requires CMS to reduce hospital payments by 1% for those ranking among the lowest-performing 25% with regards to HAC 6 6 2

3 Value-Based Purchasing (VBP) 7 Hospital-Acquired Condition Reduction Program (HAC) HAC Reduction Final Rules August, Modifiable Risk Factors 3 Characteristic Higher Risk Lower Risk Insertion circumstances Emergency Elective Skill of the inserter General Specialized Insertion site Femoral vein Subclavian vein Skin antisepsis 70% alcohol, 10% Povidone-Iodine 2% chlorhexidine Catheter lumens Multilumen Single lumen Duration of catheter use Longer duration Shorter duration Barrier precautions Submaximal Maximal 3 Adapted from TJC Monograph, APIC Guide to Preventing CLABSI,

4 What Device to Use? Inserter Perspective Infection Preventionist Perspective - Patient s Vasculature What s available? -What do they need it for? - How long do they need it? - Who s going to care for the device? - Patient s choice? - Staff/provider choice? - Anything but a central line - Shortest time possible - Least amount of lumens - Least manipulation - Where a dressing can stay intact Maintenance Checklist 4 - Hand hygiene prior to all infusion-related procedures - Aseptic technique with all catheter access procedures - Proper changing of administration sets - Changing needleless connectors according to manufacturer guidelines - Attention to disinfection of needleless connectors prior to access - Regular site care and dressing changes 4 APIC Guide to Preventing CLABSI, Where were we in 2014? 12 4

5 Where were we in 2015? 13 What does a Lean hospital do? Problems are GOLDEN! Eliminate Waste (Infections are WASTE) Problem Solve! 14 What is a Lean Management System? Strategy Deployment A3 Thinking Standard Work Quick & Easy Eliminate Waste Deliver Business Results Process Mapping Hypothesis testing Tests of Change Visual Management Value for the Patient Job Analysis Breakdown Leader Standard Work Develop People Huddles 5S 4SPS Determining root cause Sustain & Operate Regenerate & Improve 15 5

6 Lean = Strategic focus of the Organization A3 Strategic Planning Waste Tracker Job Breakdown Analysis Lean to the Front Line Incentives to Improve Continuous Improvement 16 Mother A3 17 Visibility Room 18 6

7 Baby A3 19 Division A3/Department A What are Wastes? Over Production More than needed Over Processing More work than what s required Excess Inventory More materials/product than needed Defects Errors, rework, scrap Transportation Unnecessary movement - materials Wasted Motion Unnecessary movement- people Waiting Excess time waiting Wasted knowledge Underutilizing people s talent, skills 21 7

8 Waste Metrics Tracker - Sample What does the evidence say? SHEA Compendium 5 High Evidence: Appropriate Nurse-to-Patient Ratio; minimal Floats Report rates to units Moderate Evidence: Disinfect hubs/ports before accessing Remove nonessential catheters Dressing changes every 5-7 days (nontunneled) Replace administration sets every 96 hours Special Approaches? 5 SHEA/IDSA Practice Recommendation to Prevent CLABSI, July

9 Let s examine our Failure Points! - FMEA, sponsored by Patient Safety What is a Failure Modes & Effects Analysis Proactively manage risks to prevent adverse event Identify your high-risk processes Identify your failure modes, and identify the effects For critical effects, conduct a root cause analysis Redesign the process to mitigate the risk of failures Analysis of our CLABSIs indicated probably NOT insertionrelated Central Line Processes - Blood Product Administration - Blood Draws - Vesicant/other infusions administration - TPN - Flushing - Monitoring - Dressing changes - Lab Draws - Bolus Medication Administration - Scrubbing the Hub What did our processes look like?

10 Standard Work Developed Sample Standard Work Competency Testing 1200 nurses Return Demonstrations with preceptors Covered every central line process Took 3-4 months to get to 90% 30 10

11 Tests of change - Alcohol-Impregnated swab caps added - Midline catheters introduced - Established a standard that no temporary lines leave the critical care area (staff must contact the Director to discuss) SPS Four Step Problem Solving (4SPS) Step 1: Step 2: Step 3: Step 4: Do I have a problem? Do I know the root cause? Have I confirmed cause and effect? Have I confirmed the countermeasure? 33 11

12 Step 1 4SPS Step 1: Do I Have a Problem? Big Vague Concern: Too many CLABSIs WSBH (What Should Be Happening): 0 CLABSIs WAH (What s Actually Happening): 15 CLABSIs Gap: 15 Impact: Patient Harm! $45,000/CLABSI Step 2: Do I Know the Root Cause?

13 Direct Causes of CLABSIs 37 Step 3: Have I confirmed cause and effect? SMART Goals Specific, significant, stretching Measureable, meaningful, motivational Attainable, agreed upon, achievable, acceptable, action-oriented Realistic, relevant, reasonable, rewarding, results-oriented Timely, time-based, tangible, trackable

14 Establish a Hypothesis Hypothesis: If we: 1) Adhere to 90% maintenance of central lines standard work 2) Decrease line days by 25% and 3) Achieve 90% of evidence-based environment and equipment cleaning standards Then we will decrease CLABSIs by 50% by June 30, Step 4: Have I confirmed a countermeasure? Tests of Change 1) Compliance with central line maintenance standards 2) Multidisciplinary team ask at each staff daily huddle, Can patient care needs be met without the central line? 3) Develop and comply with standards for room cleaning for each type of room 4) Develop and comply with standards for cleaning non-critical equipment

15 Unit Tracers EVS Room/Department Audits

16 46 Challenges Drawing off a central line ID diagnosis vs. IP calling a BSI caused by a central line Specimen Collection: In order to assure the integrity of the specimen and the accuracy of testing, the following general guidelines for specimen collection must be followed: - Specimen collection from the central catheter is not recommended due to the possibility of intraluminal bacterial contamination of the device. Percutaneous venipuncture from two separate sites is preferred. 5 CDC: Cultures drawn through CLs have higher rate of contamination 5 The Infection Preventionist s Guide to the Lab, APIC, Changes in the EMR Explanation: Central Line Associated Bloodstream Infections (CLABSI) can be falsely attributed to a patient when blood cultures are drawn from a central line. Moreover, best practice is to draw blood cultures only peripherally. Peripheral has been defaulted as the Specimen Source. Lab draw has been set as the default collection agent. Process instructions have been added to emphasize the need to draw peripherally. This work is mandated by the Quality Operations Council (QOC) and part of a concentrated effort to reduce CLABSI. Staff Impact: Any staff or provider entering a blood culture order

17 Challenges Scrub the Hub Moved to alcohol swab caps Use on all lines? Use only on central lines? Anesthesia too? 49 Challenges Dressing changes How much should a dressing be peeling off before you change it? How much saturated dressing prior to a change?

18 52 53 Visual Management What is it? The nervous system of Lean Management Real time view of how the process is functioning Quickly see abnormalities and can respond quickly Management at a glance Red/green = visual indicators Why is it important? What you cannot see you cannot manage 54 18

19 55 56 Sustain & Operate vs. Regenerate & Improve 57 19

20 What does the data look like? Savings Estimate: $450, CLABSI Magnet Data 59 Where do we go from here? New NHSN Baseline data Changes are no longer significant Units not achieving targets? From S&O to R&I Can we get to zero???????? 60 20

21 CLABSI Prevention Team Julie Koch, MSN, RN, CIC Dr. Martin Johnson Dr. Swati Mehta Dana Hawkes, MSN, RN Tasha Kiger, Kaizen Consultant Laura Duddy Sarah Dawson, MHT Joshua Hansen, BSN, RN JoDee Hunter, BSN, RN Deanna Stein, BSN, RN Kelly Honyak, MSN, RN Ann Alway, MSN, RN Lucille Kituku, IS Jonathan Fetterley, EVS Bijal Mehta, Kaizen Mary Hundley, Patient Advisor Mai Dotran, BSN, RN, Kaizen Consultant Dr. Jayaprakash Reddy Dr. Preethi Prakash Kristy Bond, BSN, RN Ryan Mackey, BSN, RN Sarah Barclay, BSN, RN Laura Morin, BSN, RN Sara Nash, BSN, RN Debra Jasmer, BSN, RN Beckie Sparks, MSN, RN Andrea Bell, BSN, RN Lan VoBa Dylan Nash, EVS John Doan, Business Specialist Dan Voy, Patient Advisor 61 References 1 Infusion Nurses Society. Infusion nursing standard of practice. J Infus Nurs 2011; 34(1S), S102 2 Umscheid, CA, Mitchell MD, Doshi, TA, et al. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the associated mortality and costs. Infect Control Hosp Epidemiol 2011; Feb;32(2): Goss, Linda, et al, APIC Implementation Guide to Preventing CLABSI, 2015, APIC. 5 Marschall, J., et al. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. SHEA/IDSA Practice Recommendation, Infect Control Hosp Epidemiol 2014; July;35(7):