Central Line Bundle Brochure - Achieving Excellence in Patient Care Brochure Highlights and Contact Information

Central Line Bundle Brochure - Achieving Excellence in Patient Care Brochure Highlights and Contact Information Goal: Preventing central line infections Focus: Central Line Bundle Hand Hygiene - Epi-Clenz Gel: MSC097030 (4 oz. bottle, 24ea/cs) MSC097031 (4 oz. bottle, breezia fragrance, 24ea/cs) MSC097033 (16 oz. pump 12ez/cs) MSC097034N (1.5 oz. flip cap w/ neck strap, 48ea/cs) Epi-Clenz Foam: MSC097040 (8 oz. bottle, 24ea/cs) MSC097041 (1.5 oz. bottle, 48ea/cs) MSC097042 (16 oz. bottle, 12ea/cs) Sterillium: MSC097060 (1000mL, 8ea/cs) Maximal Barrier Precautions: Full Body Drape: DYNJP4117 (10ea/cs) Maximal Barrier Precautions Kit: DYNJP4120 (6ea/cs) Chlorhexidine Skin Antisepsis: Central Line Change Tray: DYND75222 (40ea/cs) DYND75223 (40ea/cs) Optimal Catheter Site Selection: Full Body Drape -One Drape-One Solution for Multiple Access Points: DYNJP4117 (10ea/cs) DYNJP4120 Kit (6ea/cs) Daily Review of Central Line Necessity: Daily Review-Intravenous Access Record is included in the Brochure along with Policy & Procedure, Competency Statement, Skills Checklist, and Central Line Insertion Checklist A Draping Application guide is also available through Medline University at www.medline.com Contact Information: For more information on ordering the Central Line Drape or the Central Line Insertion Kit please contact Frank Czajka at (847) 775-6051 or fczajka@medline.com For more information on ordering hand hygiene products please contact April Niemi at (847) 643-4329 or aniemi@medline.com For more information on ordering our Central Line Dressing Change Tray please contact Jim Moorman at (847) 949-2262 or jmoorman@medline.com For clinical support, please contact Alecia Cooper, RN, MBA, CNOR, at (847) 643-4359 or acooper@medline.com

Achieving Excellence in Patient Care Achieving Excellence in Patient Care JCAHO 100K Lives lives Campaign saved SCIP JCAHO 100K lives saved SCIP Lives Campaign Call Toll-Free 1-800-MEDLINE Medline Industries, Inc. One Medline Place Mundelein, IL 60060 www.medline.com Proxima Full Body Central Line Drape for Maximal Barrier Protection One Drape-One Solution MediClip Surgical Clippers 2005 Medlline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. MKT205258/LIT MKT205251/LIT #174/1M #424/1M

Achieving Excellence in Patient Care Three Important National Initiatives 100,000 Lives Campaign: Six Changes for Improving Care 1. Deploy rapid response teams at the first sign of patient decline. Monitor vital signs, blood oxygen, urine output, mental function 2. Prevent deaths from heart attack by delivering evidence-based care for acute myocardial infarction. Aspirin, beta-blocker, ACE-inhibitor/ARB, reperfusion, smoking cessation 3. Prevent adverse drug events (ADEs) by implementing medication reconciliation. Verify, clarify, and reconcile patient medications 4. Prevent central line infections by implementing the Central Line Bundle. Hand hygiene, maximal barrier precautions, skin antisepsis, catheter site selection, daily review 5. Prevent surgical site infections by delivering the correct perioperative care. Antibiotics, hair removal, glucose control, normothermia 6. Prevent ventilator-associated pneumonia by implementing the Ventilator Bundle. Head of bed elevated, daily assessment, PUD prophylaxis, DVT prophylaxis 100k lives JCAHO 2006 National Patient Safety Goals for Hospitals Improve the accuracy of patient identification. Improve the effectiveness of communication among caregivers. Improve the safety of using medications. Reduce the risk of health careassociated infections. Accurately and completely reconcile medications across the continuum of care. Reduce the risk of patient harm resulting from falls. Surgical Care Improvement Project (SCIP): Four Target Areas 1. Surgical site infections Antibiotics, blood sugar control, hair removal, normothermia 2. Perioperative cardiac events Use of perioperative beta-blockers 3. Venous thromboembolism Use of appropriate prophylaxis 4. Ventilator-associated pneumonia Head of bed elevated, rapid weaning protocol, PUD prophylaxis

THE CENTRAL LINE BUNDLE PRACTICE GUIDELINES FIVE COMPONENTS OF CARE PRODUCT LISTS & INFO ITEM NUMBERS ACHIEVING EXCELLENCE IN PATIENT CARE Hand Hygiene Epi-Clenz instant hand sanitizer with ethyl alcohol kills 99.9% of common germs. It is available in convenient gel and foam versions, both with added moisturizers that leave hands feeling soft. Sterillium Rub is another alcohol-based hand antiseptic that works with out water to kill bacteria. It also contains emollients for skin protection and is available in an automatic touch-free dispenser. Epi-Clenz gel is MSC097030, MSC097031, MSC097032, MSC097033, MSC097034n Epi-Clenz foam is MSC097040, MSC097041, MSC097042 Sterillium is MSC097060 GOAL: Preventing central line infections FOCUS: Central Line Bundle Hand Hygiene Maximal Barrier Precautions Skin Antisepsis Catheter Site Selection Daily Review Maximal Sterile Barrier Precautions Chlorhexidine Skin Antisepsis Optimal Catheter Site Selection Daily Review of Central Line Necessity Medline offers a full-body drape with multiple access points and peel-off fenestration covers for versatility and ease of use. (See the enclosed information sheet on the Proxima central line drape.) Maximal Sterile Barrier Precautions Kit: Bouffant cap, face mask, sterile gown, CSR wrap, and Full Body Drape are also available from Medline in a kit. ChloraPrep friction applicators provide a convenient way to scrub insertion sites with a 2% chlorhexidine/ 70% isopropyl alcohol solution, which has been proven more effective than povidone-iodine and is recommended by the CDC as well as the 100,000 Lives Campaign Proxima Full Body Central Line Drape Two for jugular, subclavian or femoral Two for brachial, antecubital, or radial And PICC Lines Daily Central Line Review Sheet (See the enclosed sheet inside the pocket folder) DYNJP4117 Full Body Central Line Drape DYNJP4120 Maximal Sterile Barrier Precautions Kit Available February 2006 DYND75222 Central Line Change Tray DYND75223 Central Line Change Tray DYNJP4117 Full Body Central Line Drape Approximately 250,000 central venous catheter-related bloodstream infections occur each year in U.S. hospitals, with associated mortality of 12% to 25%. In ICUs, these infections cause an estimated 14,000 to 28,000 deaths per year. Additional cost to the healthcare system is approximately $25,000 per infection. On average, a bloodstream infection adds seven days to a hospital stay. TARGETED BY PATIENT CARE INITIATIVES The Institute for Healthcare Improvement s 100,000 Lives Campaign names prevention of central line infections as one of six changes for improving care. The JCAHO 2006 National Patient Safety Goals for Hospitals include reduce the risk of health care-associated infections as goal #7. A PLAN FOR PREVENTION The 100,000 Lives Campaign recommends implementing a set of evidence-based interventions, together called the Central Line Bundle, to reduce the occurrence of central line infections. POTENTIAL IMPACT OF INTERVENTIONS A four-year study in Pennsylvania found a 68% reduction in bloodstream infections among ICU patients after implementing a group of care components similar to the central line bundle. SUPPORT FROM CDC AND APIC: Recommendations in the CDC s Guidelines for the Prevention of Intravascular Catheter-Related Infections are similar to those in the Central Line Bundle. According to APIC, The elements of this central line bundle are identical to those stressed and taught by the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC). References CDC. Guidelines for the Prevention of Intravascular Catheter-Related Infections. MMWR 2002:51(RR-10). IHI. Getting Started Kit: Prevent Central Line Infections. www.ihi.org. APIC. Preventing Central Line-Associated Bloodstream Infections. 2005. CDC. Reduction in Central Line-Associated Bloodstream Infections Among Patients in Intensive Care Units Pennsylvania, April 2001 March 2005. MMWR 2005:54(40).

PRODUCT INFORMATION Proxima Full-Body Central Line Drape An important part of Maximal Barrier Precautions in the fight against central line infections. The role of maximal barrier precautions in preventing central line infections: The use of maximal barrier precautions (i.e., cap, mask, gown, gloves, and full-body drape) when inserting central lines is supported by research and recommended by current patient care initiatives. A study of cancer center patients found that the use of maximal barrier precautions during central venous catheter insertion reduced the risk of bloodstream infections. When only gloves and a small drape were used, the risk of infection was 6.3 times greater. 1 CDC guidelines recommend aseptic technique including the use of a cap, mask, sterile gown, sterile gloves, and a large sterile sheet for the insertion of CVCs [central venous catheters]. 2 The 100,000 Lives Campaign also recommends maximal barrier precautions, including covering the patient from head to toe with a sterile drape, with a small opening for the site of insertion. 3 One Drape One Solution Multiple Access Points For Convenience And Versatility Two for jugular, subclavian or femoral Two for brachial, antecubital, or radial One Drape One Solution All Access Sites The Proxima central line drape: A maximum sterile barrier with added features for convenience. Provides full-body coverage in accordance with current guidelines for preventing central line infections. Multiple access points for convenience and versatility. Clear peel-off fenestration covers are easy to open and allow insertion sites prior to positioning. 77" (196cm) visualization of Catheter-related septicemias are six times lower when maximum sterile barriers are used during central line insertion. 1 Large reinforced absorbent area surrounding access points. Reversible design allows positioning for femoral, subclavian peripheral access sites. DYNJP4117 120" (305cm) or additional Exclusive clear peel-off fenestration covers 1 Raad, II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infection Control and Hospital Epidemiology. 1994;15(4 Pt 1):231-238. 2 Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections. MMWR 2002:51(RR-10). 3 Institute for Healthcare Improvement. Getting Started Kit: Prevent Central Line Infections. www.ihi.org.

POLICY & PROCEDURE PREVENTION OF CENTRAL LINE INFECTIONS BY IMPLEMENTING THE "CENTRAL LINE BUNDLE": HAND HYGIENE MAXIMAL BARRIER PRECAUTIONS SKIN ANTISEPSIS CATHETER SITE SELECTION DAILY REVIEW POLICY STATEMENT: To reduce the patient's risk of acquiring an intravascular catheter-related infection following insertion of a central venous or pulmonary catheter through the use of a "Central Line Bundle" protocol that outlines appropriate hand hygiene, maximal sterile barriers, chlorhexidine skin antiseptic, catheter site selection, and daily review. PURPOSE: Because central line catheters provide direct vascular access to patients for the administration of fluids/medications, blood products, blood sampling, and hemodynamic monitoring, they disrupt skin integrity, making infection with bacteria and/or fungi possible. Infection may spread to the bloodstream, causing sepsis with hemodynamic changes, organ dysfunction, and ultimately death. 1 Studies suggest that bloodstream infections (BSIs) are a serious complication affecting between 87,500 and 350,000 patients annually and are associated with high mortality and excess costs. 2 HAND HYGIENE: Caregivers should wash hands (or use an alcohol-based waterless cleanser) before and after inserting or otherwise handling an intravascular catheter, as well as before and after palpating insertion sites. MAXIMAL BARRIER PRECAUTIONS: Before placing a central line, caregivers should don a cap, mask, sterile gown, and gloves. In addition, they should cover the patient s entire body with a sterile drape, leaving only a small opening at the insertion site. Skin Antisepsis: Skin should be scrubbed with a solution containing 2% chlorhexidine/ 70% isopropyl alcohol and allowed to dry completely before the site is punctured. on the reverse side: Catheter Site Selection Daily Review Maximum Sterile Barrier Procedure

Catheter Site Selection: The subclavian vein is the preferred site for nontunneled catheters in adults and should be used whenever possible instead of the jugular or femoral site. Daily Review: Lines that are no longer clearly needed should be removed promptly. Maximal Sterile Barrier Procedure: 3 1. Place surgical cap on head to cover all hair and then place surgical mask. 2. Cleanse hands according to hospital recommended policy and procedure. 3. Aseptically don surgical gown. 4. Aseptically don surgical gloves. 5. Prep catheter insertion site with ChloraPrep. 6. Place full-body sterile drape to cover patient aseptically while maintaining the sterile field. References: (1) Earsing, KA, Baugher-Hobson, D, White, KM. Preventing Central Line Infection. Nursing Management, October 2005. (2) Braum, BI, Kritchevsky, SB, et al. Preventing Central Venous Catheter-Associated Primary Infection. Infection Control and Hospital Epidemiology, December 2003. (3) Association of Perioperative Registered Nurses. 2005 Standards, Recommended Practices and Guidelines. Denver, CO, 2005.

COMPETENCY STATEMENT & SKILLS VALIDATION TOOL COMPETENCY: CENTRAL LINE BUNDLE COMPETENCY STATEMENT Good hand hygiene before central line insertion, combined with proper aseptic technique during catheter placement, has been proven to provide protection against infection. Maximal sterile barrier precautions include a surgical cap, mask, sterile gown, sterile gloves, and a full-body sterile drape during the insertion of central line catheters. Proper skin antisepsis is critical prior to insertion of central line catheters to reduce local skin flora and to prevent rapid rebound growth of microorganisms on the skin s surface following catheter insertion. The site at which a catheter is placed influences the subsequent risk for catheter-related infection and phlebitis. Daily review of central lines is a necessity, with documentation in the medical record. MEASURABLE CRITERIA Good hand hygiene can be achieved through the use of either a waterless, alcohol-based product or an antibacterial soap and water with adequate rinsing. Implementation of maximal sterile barrier precautions during the insertion of central line catheters has been shown to substantially reduce the incidence of catheter-related bloodstream infections as compared with sterile precautions (e.g., sterile gloves and small drape). Optimal skin antisepsis is achieved when skin is prepared with a solution containing 2% chlorhexidine/ 70% isopropyl alcohol and allowed to dry completely before the site is punctured. Authorities recommend that central venous catheters be placed in a subclavian site instead of a jugular or femoral site to reduce the risk of infection. A daily review of the catheter patency and insertion site is necessary, combined with the daily question, "Is this catheter necessary or can it be removed?" RATIONALE The purpose of good hand hygiene is to remove debris and transient microorganisms from the hands, to reduce resident microbial count to a minimum, and to inhibit rapid rebound growth of microorganisms. Personnel within a sterile field should wear caps, masks, and sterile gowns and gloves to prevent microorganisms from being transferred to the catheter insertion site during the procedure. Infection can occur due to a high microbial count at the catheter insertion site. The density of skin flora at the catheter insertion site is a major risk factor for catheter-related blood stream infections. Lines that are no longer clearly needed should be removed promptly to eliminate the potential for catheterrelated bloodstream infections.

SKILLS VALIDATION CHECKLIST: CENTRAL LINE BUNDLE EMPLOYEE S NAME: DATE: REVIEWED DEMONSTRATED TASK DATE/INITIALS DATE/INITIALS COMMENTS 1. Identify self 2. Identify patient 3. Explain procedure to patient 4. Obtain signature for informed consent. 5. Wash Hands 6. Gather necessary equipment: Central line bundle kit Central line catheter kit 7. Provide for Privacy (pull curtain, close door) 8. Position patient to allow for visualization of surgical site. 9. Assess patient's skin at insertion site prior to skin preparation. Assess for moles, warts, rashes, hair, and other skin conditions at the surgical site. 10. Remove any hair if ordered by physician. 11. Document skin assessment in the patient's record. 12. Assemble equipment and verify supplies. 13. Apply surgical hat and mask and secure in place. 14. Wash hands with approved antiseptic agent. 15. Don a sterile surgical gown and gloves aseptically. 16. Prep procedure site with ChloraPrep. Allow 30 sec. prep time & 30 sec. dry time for a dry site & 2 min. prep time and a 1 min. dry time for a moist site. 17. Apply full-body drape aseptically to establish the maximal barrier. Remove tab from insertion site. 18. Maintain a sterile field during the catheter insertion. 18. Order followup Radiology images if ordered by physician. 19. Utilize sterile technique when applying the dressing to the catheter insertion site. 20. Date the dressing site. 21. Document procedure and patient tolerance in the medical record. 22. Add IV site to appropriate flowchart(s).

CENTRAL LINE INSERTION CHECKLIST

INTRAVENOUS ACCESS RECORD Line type Location Site Appearance Procedure 1. Peripheral 1. Left Hand 1. Site unremarkable 1. I.V. Start/Restart 2. PICC 2. Right Hand 2. Slightly pink or painful 2. Dressing change 3. Midline 3. Left forearm 3. Painful: slightly red 3. Cap Change 4. Multi Lumen 4. Right forearm 4. Painful: erythema, swelling 4. Central Line placement 5. Port-a-cath 5. Left upper arm 5. Purulent drainage 5. Discontinued line 6. Dialysis 6 Right Upper Arm 6. Serous drainage 6. De-clot therapy 7. Hickamn 7. Left Chest 7. Serosanguanous drainage 7. Tubing change 8. Swan Ganz 8. Right chest 8. Sutures intact 8. Port-a-cath access 9. Cordis 9. Left neck 9. Cording palpable 9. Port-a-cath de-access 10. Other 10. Right neck 10. Other 10. I.V. securement applied (see comments) 11. Left foot (see comments) 11. Other 12. Right foot (see comments) 13. Other (see comments) Date/Time Line Type Location IV Access Site Procedure Signature Next of Line Gauge Attempts Appearance Activity

MAXIMUM BARRIER DRAPING APPLICATION GUIDE DYNJP4117 Proxima Full Body Central Line Drape STEP 1 Open the package containing the Full Body Drape using aseptic technique and place the drape on an established sterile field. The sterile field can be established by using the inside wrapper containing the drape. It is recommended that the person applying the drape have also adhered to hand hygiene and full barrier precautions, including hat, mask, sterile gown, and sterile gloves prior to applying the drape. The applicator should then note the specific orientation instructions stamped onto the drape. STEP 2 Remove the carrier paper from the back of the insertion fenestration that will be utilized to insert the catheter. STEP 3 Assure the proper orientation of the drape over the patient according to the designated catheter insertion site and place the folded drape over the patient at midline. STEP 4 Unfold the drape to the right and to the left as indicated on the drape to cover the patient's body and then unfold the drape to the head and then to the foot. Assure the patients entire body is covered and that the insertion site is exposed for proper catheter placement STEP 5 Remove the plastic film covering the selected insertion fenestration to provide access. You are now ready for insertion of the central line catheter.