HEN 2.0 CLABSI WEBINAR NAILING CLABSI PREVENTION! February 11, 2016 11:00 a.m. 12:30 p.m. CT 1
WELCOME AND INTRODUCTIONS Kimberly King, Program Specialist, HRET 11:00 11:05 2
WEBINAR PLATFORM QUICK REFERENCE Mute your computer audio Download today s slides and resources 3
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
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
HEN DATA UPDATE Rich Rodriguez, Data Analyst, HRET 11:05 11:10 6
CLABSI HEN 1.0 SUCCESSES 7
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
CLABSI EVALUATION MEASURES 9
CLABSI EVALUATION MEASURES 10
CLABSI EVALUATION MEASURES
CLABSI PROCESS MEASURES
CLABSI PROCESS MEASURES
CLABSI PROCESS MEASURES
CLABSI PROCESS MEASURES
Central line maintenance It s not glam but got to nail it! Cheryl Ruble, Improvement Advisor, Cynosure Health 11:10 11:25 16
CLABSI 46% decrease between 2008 & 2013! National And State Healthcare Associated Infections Progress Report CDC, Jan. 2015 http://www.cdc.gov/hai/pdfs/progress-report/hai-progress-report.pdf 17
Your Plan CLABSI Rate Time 2008-2013
2014 CLABSI Definition changes 19
CLABSI Rate Time 2014-2015
CLABSI Prevention Maintenance bundle 21
CLABSI Prevention Maintenance bundle 22
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, 2011. Retrieved at: CDC Guidelines http:/ www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf 23
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
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. 2013 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):247-249. Consider patient allergies
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
RESOURCES HRET HEN Infections LISTSERV. Sign up at http://www.hrethen.org/inc/dhtml/listserv.dhtml HRET HEN CLABSI Resources and Change Package http://www.hrethen.org/topics/clabsi.shtml 27
CASE STUDY: HOSPITAL STORY Kern Medical 11:25 11:40 28
KERN MEDICAL, BAKERSFIELD, CA Kristi Wood, RN, BSN, CIC, Infection Control Coordinator Dianne McConnehey BSBA, RNC, CPHQ, Director of Quality 29
ABOUT US County owned/operated since 1934 222 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
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
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
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
KERN MEDICAL S 5 YEAR JOURNEY 35
4.5 4 3.5 KERN MEDICAL QUARTERLY CLABSI RATES 2011-2015 4.1 Last CLABSI in NICU 10/7/2011 3 2.5 2 1.5 1 0.5 0 1.2 2.1 2.6 1.8 0.4 0.5 0.5 0 0 0.5 0.4 1 CLABSI in ICU Patient 6/2/15 2/27/14 6/1/15 16 months no CLABSI 0 0 0 0 0.6 0 0 36
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
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
OUR TEAM 39
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 661-326-2696 mcconned@kernmedctr.com Kristi Wood, RN, CIC 661-326-2811 or woodkr@kernmedctr.com 40
Hardwiring a Reliable Process for Reproducible Results Maryanne Whitney, Improvement Advisor, Cynosure Health 11:40-12:00 41
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.
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?
IS YOUR CENTRAL LINE INSERTION PROCESS RELIABLE? WHY?
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
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
CHARACTERISTICS OF HIGH FAILURE PROCESSES No articulated common process Emphasis on training and reminders
Characteristics of Low Failure Processes Processes intentionally designed with tools and concepts to prevent or mitigate human errors (human factors engineering)
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)
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
Attaining Reliability Three Step Process 1. Prevent Failure 2. Identify and Mitigate Failure that occurs 3. Redesign to Eliminate Critical Failures that have occurred
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
MYTHS 1 &2 The evidence is in: Hard work & vigilance along with education & training is not enough!
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
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
Reminders and Visual Clues
Differentiation Reduce confusion when contents, names or numbers are similar Color coding Identify items in easily distinguishable ways
Constraints Restrict or limit the performance of certain actions Sizing parts differently
Affordances Provide clear visual or other sensory clues that lead the user to use a product or tool correctly, or perform the correct action
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.
MYTHS 3 & 4 Together: Process & structural changes drive outcome
Step 3: Redesign 1. Root Cause Analyses What did happen? 2. Failure Modes and Effects Analysis What might happen? 3. Learning Loop Performance feedback
Redesign Central Line Maintenance Engineered for success Alcohol impregnated caps CHG bathing Securement devices EHR reminders and reports
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?
Easy to do the Right Thing Make it hard to do the wrong Make thing it hard to the wrong thing
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.
QUESTIONS
BRING IT HOME Kimberly King, Program Specialist, HRET 12:00 12:15 69
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
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
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
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
THANK YOU! Find more information on our website: www.hret-hen.org Questions/Comments: hen@aha.org 74