SE5p, CLABSI Education.pdf. Central Line Education: Focus on CLABSI 2009

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1 Central Line Education: Focus on CLABSI

2 Why are you here today? 2 2

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5 Opportunities for Blood Stream Infections R/T Central Lines A Central Line is the highway onramp to the circulatory system When caring for a central line you are entering a vulnerable sterile space! 5 5

6 Organisms can be introduced into the bloodstream: During insertion At insertion site When a central line is opened or broken into When a central line is accessed for blood draws or medication administration During discontinuation 6 6

7 Goal: to improve the care and maintenance of central lines in order to decrease central line infections Focus of Education: Focus of today s education will be on the components of the policy that are geared toward prevention of central line infections 7 7

8 What we need from you Commitment to learning the revised process Commitment to reducing central line infections Belief that we can eliminate central line infections Identifying nursing care as a major factor for reducing central line infections 8 8

9 What will be covered today: Background of CLABSI (Central line blood stream infection) Insertion of Central line Your role (the RN) during the insertion process Patient education Monitoring for Aseptic Insertion Technique How to care for the central line/policy change Dressing changes Tubing, Clave, and stopcock changes Accessing the line Discontinuing the line 9 9

10 What will be covered today: Central Line Tip culture Nursing Daily Indication Assessment Documentation Summary of Nursing Documentation 10 10

11 Background 11 11

12 Definitions HAI: Healthcare-associated infection CVAD: Central Venous Access Device CLABSI: Central Line-associated Bloodstream Infection CHG: Chlorhexadine Gluconate CDPH: California Department of Public Health CLIP: Central Line Insertion Practices CDC: Centers for Disease Control & Prevention 12 12

13 Cleanliness Issues Famous Reporter's Routine Procedure Turned into Horrible Death, Family Says ABCNEWS.com N E W Y O R K, Oct. 23 Well known to America as a television sports reporter and author, Dick Schaap's 50-year career brought him to the heights of prestige and privilege until his unexpected death. The media has raised awareness about HAIs 13

14 HAI s affect real people The public is becoming more & more aware of infections acquired during health care The public is realizing these infections can be prevented & expect prevention to occur 14 14

15 Background There is a focus on certain HAIs, such as CLABSI--- Why? 1. High mortality (12-25% increased risk of death) 2. High morbidity (increased risk of dangerous complications, extended LOS) 3. High cost ($25,000-$56,000 per episode) 4. Most are preventable We are all affected---when we are patients & when we pay for our health insurance It s the right thing to do for others & ourselves 15 15

16 Result of Focus: October 1,2008 Medicare no longer will pay for hospital infections caused by inter-vascular catheters. Background 16 16

17 Background Result of Focus: 1/1/09 New CA. law requires hospital CLABSI to be reported to CDPH Law also requires reporting of CLIP compliance 1/1/11 Data will be provided to the public by name of the facility 17 17

18 Background Multiple organizations have identified specific practices to reduce the risk of CLABSI These practices have become the standard of care for CVAD s nationally Focus is on sterile insertion, maintenance, access, & prompt removal 18 18

19 Background Example: 2003 The Institute for Healthcare Improvement (IHI)--- Bundled practices that showed evidence of preventing CVAD infection: 1. Hands cleaned prior to procedure 2. Use of maximal barriers 3. Use of CHG to prep site 4. Use of preferred site (sub-clavian) 5. Line is assessed daily & removed ASAP Now referred to as CLIP 19 19

20 UC Campus Rates Comparison UC BSI Rate Fall 2008 Q1 FY 2009 Q1 FY 2009 Q2 FY 2009 Q2 FY 2009 Q3 FY 2009 Q3 FY 2009 (adult ICUS excluding burns) Rate/100 0 Line Days Rate/ 1000 Line Days change from 2008 Average Rate/ 1000 Line Days change from 2008 Average Rate/ 1000 Line Days change from 2008 Average UCD % % % UCI % % % UCLA RR % % % UCLA SM % % % UCSD % % % UCSF % % % Total % % % 20 20

21 Definition of a Central Venous Access Device (Central Line) SE5p, CLABSI Education.pdf CDC Definition: An intravascular catheter that terminates at or close to the heart or in one of the great vessels which is used for infusion, withdrawal of blood, or hemodynamic monitoring. Examples: Non-tunneled-Multi-lumen catheter, Swan, Cordis Tunneled-Hickman, Broviac, Port Dialysis non-tunneled-quinton Dialysis tunneled PICC Thermoguard 21 21

22 Definition of CLABSI CDC criteria requires a positive blood culture Contaminated blood cultures can be misleading may result in inappropriate antibiotics for patient Could get inappropriately counted as a CLABSI Blood cultures are more likely to be contaminated if drawn through a line Do not draw blood for a blood culture through a line unless specifically ordered At least 1 culture should be drawn from a peripheral site 22 22

23 Insertion of Central Lines 23 23

24 The RN Role during Insertion of Central Lines Patient/family education Central Line Associated BloodStream Infection (CLABSI) Prevention handout Monitoring for aseptic insertion technique Central Line Insertion Practice (CLIP) checklist SE5p, CLABSI Education.pdf 24 24

25 Patient/Family Education JCAHO National Patient Safety Goal January 1, 2010 Prior to insertion of a central venous catheter, the hospital educates patients and, as needed, their families about central line associated bloodstream infection prevention. Prior to insertion is preferred, but may not always be possible or appropriate. For example, if a patient is having a line placed emergently, or placed unexpectedly during surgery

26 Sharepoint Directory 26 26

27 Patient Health Education 27 27

28 Click Link 28 28

29 Patient Education Material in English and Spanish 29 29

30 CLABSI Education handout 30 30

31 Documentation of Teaching Med-Surg Flowsheet Critical Care Flowsheet TimeOut Form 31 31

32 Critical Care Flowsheet Document in Nurses notes Documentation should be: Central line FAQ reviewed with patient/family, handout provided 32 32

33 Medical Surgical Flowsheet Document in Micromedex/Carenotes section of flowsheet Documentation should be: Central line FAQ reviewed with patient/family, handout provided 33 33

34 Time-Out CheckList: IR & Procedural Areas Documentation should be: Central line FAQ reviewed with patient/family, handout provided SE5p, CLABSI Education.pdf 34 34

35 Outpatient Clinics Documentation will be on the Pre-op patient education Checklist Currently in committees Anticipated implementation date: 10/

36 CLIP Checklist Applicable to target areas: All central lines inserted in an ICU All PICC lines inserted in an inpatient All central lines inserted in ED, IR, and OR Data is submitted by law to California Dept of Public Health (CDPH) for public reporting Role of recorder: Monitor and document proper aseptic technique, adherence to best practices Stop the Line when breaches are observed 36 36

37 CLIP form 37 37

38 CLIP Maximal Barrier Precautions Cap, Mask, Sterile Gloves, Sterile Gown Head to Toe Sterile Drape 38 38

39 CLIP form Make sure ALL items are completed If you observe non-compliance, STOP THE LINE! Speak up and inform the inserter of the concern, don t just document non-compliance. Submit forms per unit, forms are forwarded to EIP weekly Non-compliant forms are addressed by the Attending Physician or Medical Director and the Nurse Manager

40 What s wrong with this CLIP photo? 40 40

41 Inserter missing CAP STOP THE LINE: Dr. X, I noticed you are missing a cap, here s one so we can be compliant with maximal barrier precautions, THANKS! 41 41

42 What s wrong with this CLIP photo? 42 42

43 Inserter missing MASK Dr. X, your pager is beeping like crazy! just kidding, you forgot to put on your MASK for maximal barrier precautions. Dr. X, you have a very handsome face, but this procedure requires you to put on a mask for maximal barrier precautions 43 43

44 What s wrong with this CLIP photo? 44 44

45 Inserter not using head to toe drape SE5p, CLABSI Education.pdf Dr. X, we re supposed to be using a HEAD to TOE DRAPE for central line insertions, let s get you one before we start

46 Your Turn What else could you say????? 46 46

47 Care, Maintenance & Discontinuance 47 47

48 1. Dressing changes 2. IV tubing, Connector, and Stopcock Change protocol 3. Line access 4. Blood draws 5. Discontinuance/Obtaining tip for culture 48 48

49 Basic Principles Any gauze dressing will be changed every 24 hours All CVAD dressing changes with transparent occlusive dressings will be changed 2 times per week on Sundays & Thursdays Sunday night shift Thursday day shift 49 49

50 Basic Principles PRN dressing changes should occur for the following conditions: Dressing is lifting Visible moisture Bloody drainage is present Visibly soiled Dressing becomes contaminated ***All of these conditions are a set up for a central line infection at the insertion site*** 50 50

51 Basic Principles: Transparent Occlusive Dressing Transparent occlusive dressing should look like this Dressing changes: Sunday Night shift Thursday Day shift Phote of transparent occlusive dressing 51 51

52 Basic Principles: Gauze Dressing Gauze dressing should look like this Gauze dressing should be changed every 24 hours Initial and Date Note: Opsite with PICC only, if not PICC gauze & tape only Photo of guaze dressing 52 52

53 Gauze & Transparent dressing should NOT be combined (unless it is a PICC line) 53 53

54 Basic Principles: PICC Lines & Stat-lock Stat-lock should be changed with each PICC line dressing change Cleansing of site should be done after Stat-lock has been removed 54 54

55 Basic Principles: IV Tubing, Connector, & Stopcock Change Maintenance IV tubing, connectors, stopcocks, and extension tubing will be changed every Sunday and Thursday with dressing change Claves and central line ports will be changed with each dressing change on Sunday and Thursday 55 55

56 Basic Principles: Claves Claves are sterile out of the package Claves must be scrubbed prior to entry into the line Scrub the hub of the clave with an alcohol wipe to a count of

57 Basic Principles: CVAD Access Hands must be cleaned before handling IV tubing or accessing the central line through any port Scrub the Hub of any port or clave with alcohol for a count of 10 for any nontunneled central line 57 57

58 Scrub the Hub Injection port to be disinfected/scrubbed with alcohol vigorously for a count of 10 Alcohol must be allowed to dry prior entry of any port on a central line When to Scrub the Hub: Entry into any IV port Entry into any port of stopcock When connecting IV tubing during tubing changes Prior to medication administration Prior to blood draws 58 58

59 Basic Principles: Blood Draws Clean hands before handling IV tubing or accessing the central line thru any port Clean clave with alcohol using Scrub the Hub procedure Draw blood through clave Change clave after blood draw Clean clave with alcohol prior to reconnecting to tubing 59 59

60 Basic Principles: Blood Draws Always use blue end stop cap on end of IV tubing to maintain sterility of tubing NEVER loop back and connect end port to IV tubing Blue end caps are one time use only Flush catheter/port with 10 mls (adults) / Peds 3 mls normal saline using push pause technique Flush catheter/port per SNP or reconnect to running IV fluid 60 60

61 Dressing Change Procedure Steps of dressing change procedure The following slides will demonstrate the steps involved in the dressing change Why should this be a priority: The patient is my priority 61 61

62 Identify & Clean Prep Area 62 62

63 Gather Dressing & Tubing Change Supplies 63 63

64 Clean Hands 64 64

65 Apply Clean Gloves 65 65

66 Prepare for Tubing Change Prime all new lines with new stopcocks and claves Change claves on central line All tubing, stopcocks & connectors to be changed during shift Keep ends sterile Change medication, tubing & connectors as tolerated by patient Label tubing 66 66

67 Prepared Tubing will be hanging from IV Pole 67 67

68 Perform Central Line Dressing Change SE5p, CLABSI Education.pdf Gather Supplies 68 68

69 Clean Hands 69 69

70 Apply Clean Gloves 70 70

71 Open Central Line Dressing Kit to First Level Note: Sterile gloves, mask and hand gel in this part 71 71

72 Apply Mask & Put on Clean Gloves 72 72

73 Remove old Dressing/Remove Stat-Lock & Discard (Use Alcohol Wipe as Necessary) 73 73

74 Open kit to Inner Level 74 74

75 Open Stat-Lock onto Field for PICC line 75 75

76 Use Hand Gel in Dressing Kit 76 76

77 Apply Sterile Gloves 77 77

78 Clean Insertion Site Thoroughly with Chloraprep 3 swabs 30 seconds for dry 2 minutes for moist sites Let site air dry If oozing: PICC: gauze with opsite All other: gauze with tape only (from kit) SE5p, CLABSI Education.pdf 78 78

79 Assess Insertion Site Clean & Dry Redness Induration Other signs of infection Document site condition on flowsheet any interventions should be notes on narrative note 79 79

80 Apply Skin Protectant 80 80

81 Apply New OpSite (& Stat-lock if PICC) 81 81

82 Label the dressing Date inserted & initials Date Dressing changes & initials 82 82

83 Connect New IVs, Tubing & Connectors: Remember to Scrub the Hub 83 83

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85 Coban may be placed at PICC line insertion: Remove during initial dressing change. Should be removed in initial 24 hours 85 85

86 Document Dressing Change & Site Appearance on Flowsheet 86 86

87 Discontinuance 87 87

88 PICC Line 1. Clean hand, use non-sterile gloves 2. Remove old dressing and Stat-lock 3. Patient s arm straight in a relaxed position 4. Pull 3-4 centimeters at a time until catheter is removed No pressure to insertion site during removal 88 88

89 5. Measure Catheter after removal 6. Place 2x2 gauze dressing and tape at the insertion site 7. If tip appears not to be intact, contact the patient s physician and obtain a chest x- ray 89 89

90 All other CVADs 1. Turn off IV, clamp tubing and remove dressing 2. Head of bed flat, as tolerated (trendelenberg not recommended) 3. Cleanse skin with Chlorhexidine (appx. two inches in diameter) 4. Carefully cut and remove sutures 5. Place 4x4 dressing lightly over site 90 90

91 6. Instruct patient to take a deep breath and hold for several seconds For patients on mechanical ventilatio, withdrawal during expiration 7. Withdrawal catheter in one continuous motion 8. Apply pressure over site 5 minutes for central 10 minutes for femoral 91 91

92 Tip for Culture Use Chlorhexidine to cleanse skin and catheter Remove catheter without contaminating tip Cut tip with pair of sterile scissors Drop into culture tube Tip Culturing is Discouraged 92 92

93 Your Turn Time to Demonstrate 93 93

94 Daily Indication Assessment 94 94

95 Daily Indication Assessment Each central line must be assessed daily to determine if it is still needed Daily assessment must be performed both by the nurse & the physician The nurse will document in TDS the indication for the line when acuities are entered If line no longer indicated, notify MD 95 95

96 Daily Indication Assessment Each shift, determine if each central line your patient has meets one of these indications for use: 1. Monitoring (e.g. CVP) 2. Therapies (e.g. medications requiring longterm administration (> 14 days), TPN, dialysis/pheresis 3. Rapid infusion of large volumes of blood/fluid 4. Unable to obtain alternate IV access 96 96

97 Daily Indication Assessment If the line does not meet a continued indication for use, contact the physican to discuss a plan for removal CA. law requires daily documentation by the physician for daily line indication A stamp will be placed on the Nursing Flowsheet for this documentation OR it will be documented in the MD progress notes MD must document need for line each day until discontinued 97 97

98 Documentation 98 98

99 Physician Documentation The physician must document daily the necessity of the central line 99 CVAD Policy: Page 2 99

100 Nursing Documentation Summary of Nursing Documentation Patient Education: FAQs Catheter-Associated Bloodstream Infection on flowsheet Date and type of central line inserted on the flowsheet CLIP form completed Dressing change (on flowsheet) Tubing change (on TDS or flowsheet) Site appearance (on flowsheet) Interventions noted on nursing narrative note

101 Staff Trainers/Unit Resources 3Tower Caleb Howard 4 Tower Antonia Lopez (Ramos) 4 Tower Hoanglan Nguyen 4T Irene Ong BICU Michelle Grywalski BICU Kimberly Roberts MICU/CCU Doris Sanders NSCU Diana Chairez ONC Van Le ONC Jennifer Youngmark PPCU Sarah Quing SICU Angie Camacho SICU Sheryl Heffernan SICU Linly Sarno SICU Maria Asidor SICU Kathleen Hoff SICU Naomi Chester SSDU Israel Abejar SSDU Haydee Panganiban SSDU May Reyes UH 58 Sung Lee UH 58 Rachelle Mendoza

102 CLABSI Performance Improvement Team Deborah Thompson Linda Dickey Kathleen Quan Mariya Kovryga Kornick Maurice Espinoza Brooke Baldwin-Rodriguez Jun Balba SE5p, CLABSI Education.pdf

103 Staff Trainers/Staff Resources