Management of Central Venous Access Devices Institute for Healthcare Improvement (IHI)
Purpose The purpose of this e-learning module is to help educate patient care providers on the Institute for Healthcare Improvement initiatives and how these IHI initiatives will help increase patient safety. Instructions In order to complete this e-learning module you must: 1.Read the entire e-learning module 2.Complete and answer all the questions in the post assessment on the 3.Proceed to next e-module
Objectives 1. Identify the. 2. Explain how the are implemented by the indicated BUNDLES.
THE INSTITUTE FOR HEALTHCARE IMPROVEMENT (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action.
The Campaign Goal: to protect patients from five million incidents of medical harm over the next two years Some is not a number. Soon is not a time. The number is five million. The time to start is now.
Initiatives and BUNDLES Reconciliation of Medications (to prevent adverse drug events) Deployment of Rapid Response Teams Improving care for AMI (Acute Myocardial Infarction) Prevention of VAP (Ventilator Acquired Pneumonia) Prevention of CLAB s (Central Line Associated Bacteremias) Prevention of SSI (Surgical Site Infections) Prevent Harm from High-Alert Medications... focus on anticoagulants, sedatives, narcotics, and insulin Reduce Surgical Complications... implement SCIP recommendations - Surgical Care Improvement Project Prevent Pressure Ulcers... use science-based guidelines for prevention Reduce MRSA infection implement scientifically proven infection control practices Deliver Reliable, Evidence-Based Care for Congestive Heart Failure... to avoid readmissions
What is a Bundle? A "bundle" is a collection of processes needed to effectively and safely care for patients undergoing particular treatments with inherent risks. Several interventions are "bundled" together and, when combined, significantly improve patient care outcomes. Retrieved from:http://www.ihi.org/ihi/
Now Let s Look at the Bundles
1. Reconciliation of Medication and Improving Care for AMI Since these are captured under the Joint Commissions Goals they are reviewed with National Patient Safety Goals module
2. Deployment of Rapid Response Teams (RRT) RRTs came about to address: Failures in planning (assessments, treatments, goals) Failure to communicate (patient to staff, staff to staff, staff to physician, etc.) Failure to recognize deteriorating patient condition You will review this in detail when you review RRT in orientation.
3. CLABs: Central Line Associated Bacteremia CVC s (central venous catheters) disrupt the integrity of the skin and may cause infection which may spread to the bloodstream causing sepsis Approximately 90% of catheter related bloodstream infections occur with Central Venous Catheters Goal: To prevent catheter related bloodstream infections by implementing the 5 components of care called the central line bundle
Incidence and Impact 45% of ICU patients have CVC s Fatality rate for CLAB s is 20% Length of Stay increased by mean of 7 days Cost $3,700- $29,000 per infection Between 500-4000 patients in the US die each year due to blood stream infection
CLABs Central Line Associated Bacteremia Bundle components Optimal Hand Hygiene always Maximal barrier precautions use Chlorhexidine skin antisepsis use Optimal catheter site selection (femoral is least desirable) Daily review of line necessity Appropriate administration system/ equipment care (ie: tubing care, dressing care)
CLAB s - Hand Hygiene 101 When caring for central venous catheters, cleanse hands with soap and water: Before and after palpating catheter insertion sites Before and after inserting, replacing, accessing, repairing or dressing and intravascular catheter Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained
Do you know the hand hygiene rules?
NSLIJHS Hand Hygiene Policy Handwashing and the use of alcohol-based hand rubs are effective means for preventing the spread of infection in the hospital setting. The use of gloves does not eliminate the need for hand washing! Hospital approved liquid soap from wall dispensers in patient care areas shall be used when hands are visibly soiled. Bar soap is for patient use only. When hands are not visibly soiled alcohol-based hand rubs may be used. *For hand washing procedure in areas such as the NICU, Perioperative Services, Bone Marrow Unit, and other special procedure areas refer to the unit specific manuals.
NSLIJHS Hand Hygiene Policy I. Hands shall be washed thoroughly: When visibly soiled II. Hand hygiene must be employed: Before and after patient care After contact with blood, bodily fluids, mucous membranes, secretions, excretions, and non intact skin even if gloves are worn After contact with an inanimate object that is potentially contaminated Before handling food After using the bathroom, eating, coughing or sneezing Before/ after donning gloves Before administering medication Before/ after performing an invasive procedure
NSLIJHS Hand Hygiene Policy Alcohol based cleansers: Alcohol based hand gel is appropriate for hand antisepsis before and after patient care, except when hands are visibly soiled. When using an alcohol-based handrub, apply the product to the palm of one hand and rub hands together. All surfaces of the hands and fingers must be covered. The hands must be rubbed until dry.
NSLIJHS Hand Hygiene Policy **You will be asked to demonstrate hand hygiene in orientation III. Handwashing procedure with soap and water is as follows: Jewelry (except wedding bands) should be removed Wristwatches shall be removed or moved up onto the arm Turn on water, adjust temperature Wet hands and wrists before applying soap Keep hands downward so water will run into sink and not down arms Apply soap and scrub vigorously on all hand and wrist surfaces for 10 to 15 seconds Rinse thoroughly under running water keeping hand downward Dry hands with paper towel, discard paper towel If using sink with hand controls, turn off faucet with clean paper towel Discard paper towel
NSLIJHS Hand Hygiene Policy Nails: Healthcare workers who wear artificial nails are more likely to harbor pathogens on their fingertips than those who have natural nails. Artificial nails or wraps shall not be worn by staff having direct hands-on contact with patients. Natural nails should be no longer than ¼ inch long Nails should be free of chipping polish and any glued on ornamentation
Hand Hygiene Rules For how long should you wash your hands?
Answer: 15 seconds (tip: sing Happy Birthday song twice while washing hands) Note: The only acceptable jewelry to remain on during hand hygiene is a wedding band. Watches must be moved up the arm.
Hand Hygiene Rules What is the key action for good handwashing?
Answer: Friction
Hand Hygiene Rules What are some of the differences between a regular handwash and a surgical scrub?
Answer: For surgical scrub: Length of time (120 seconds) Distance covered (fingertip to elbow) Stronger Antimicrobial used
Hand Hygiene Rules What is the NSLIJHS policy on artificial nails?
Answer: Not allowed! (includes tips and wraps; no glue of any sort)
Hand Hygiene Rules How long are your nails allowed to be?
Answer: ¼ inch from fingertip
CLAB s - Insertion Site Preparation Avoid removing hair, if necessary use scissors or clip Avoid shaving Avoid femoral site; subclavian or IJ preferred Antiseptic solutions: Prepare skin with CHLORHEXIDINE (chloraprep) Press sponge against skin using a back and forth friction scrub for at least 30 seconds Allow to air dry Do not repalpate after cleansing
CLAB s - Maximal barrier precautions For the provider: Hand hygiene Non-sterile cap and mask all hair goes under the cap Sterile gown and gloves For the patient: Cover the patient s head and body with a large sterile drape
CLAB s - Care of the catheter Dressings- transparent dressings are changed at least every 7 days Site care- cleanse skin around insertion site with and alcohol swab and re-apply chloraprep and sterile dressing when needed Change dressing when wet, loose or soiled Do not apply antimicrobial ointment (ie: povidone-iodine) to site except for hemodialysis catheters
CLAB s - The BIO-PATCH Chlorhexidine gluconate impregnated opaque foam patch may be used over insertion site (typically used in ICU s)
CLAB s - System Maintenance Replace IV tubing, including stopcocks, at 96 hrs. Clean injection hubs, connections and sampling ports with alcohol and air dry before accessing Replace tubing used to administer blood and blood products, and lipids within 24 hours of initiating the infusion Change Diprivan (Propofol) tubing every 12 hours Parenteral nutrition should have a designated port
CLAB s - Monitoring and Assessing Assess the need for the central line daily and discontinue when no longer needed Visually inspect the catheter site daily for signs of local infection Palpate the catheter insertion for tenderness
CLAB s - Monitoring and Assessing Assess the patient for systemic infection (ie temp, WBC s) Examine cannula insertion site during exit site care and if the patient is febrile Culture blood, insertion site (where drainage is present) if catheter related infection is suspected
CLAB s - Key Change Document the compliance with the insertion bundle criteria immediately after insertion (use central line insertion form) Create a culture of safety and prevention- stop the procedure if improper techniques are used
4. Ventilator Acquired Pneumonia VAP Bundle Goal: To prevent ventilator associated pneumonia (VAP) and deaths from VAP and other complications in patients with ventilators by implementing the four components of care called the VAP bundle
VAP Bundle- Ventilator Acquired Pneumonia Incidence 15% of all hospital acquired infections 20-33% attributable mortality rates Increased ICU stay by 4.3-6.1 days Excess costs of approximately $40,000/patient (CDC, 2003) Incidence ranges from 9% to 70%. Increases average hospital stay from 6 days to > than 30 days. Rumbak, M. J. (2000). Strategies for prevention and treatment. Journal of Respiratory Disease, 21 (5), p. 321.
VAP Bundle- Ventilator Acquired Pneumonia VAP is no longer just an unfortunate hospital related occurrence It is viewed as medical error Risk Factors #1 risk factor -endotracheal intubation and mechanical ventilation! Administration of antibiotics Admission to ICU Underlying chronic lung disease
VAP Bundle- Ventilator Acquired Pneumonia Elevate HOB 30-45 degrees Daily sedation vacation Daily assessment of readiness to extubate Peptic ulcer prophylaxis Deep venous thrombosis prophylaxis
VAP - Sedation Vacation Definition: daily interruption of sedation to assess readiness for extubation Reduces overall patient sedation and vent dependency Promotes early extubation with no significant increase in self- extubation Issues and concerns: Self extubation, anxiety, desaturation
5. Surgical Site Infection Bundle (SSI) Goal: Prevent Surgical Site Infections Prophylactic peri-operative antibiotics (choice and timing are critical) Appropriate hair removal Peri- and post- operative glucose control Perio- and post- operative normothermia
SSI - Antibiotics Must be given within 1 hour before surgical incision Discontinuation of antibiotics within 24 hours after surgery
SSI - Hair Removal Appropriate No hair removal at all 100% compliance with the use of clippers Removal of razors from the OR Depilatory use (hair removal cream) Not Appropriate Shaving
SSI - Normothermia Hypothermia can negatively affect the immune response Keep pt. warm pre-op Use warmed fluids Increase the ambient temp in OR Use warming blankets Hats and booties on patients
SSI- Glycemic Control Goal: keep glucose at normal levels Begin protocol at glucose level of 150. Ideal patient blood sugar range: 90-120mg/Dl
Additionally for SCIP measures (Surgical Care Improvement Project) Peri-op beta blocker *** Venous Thromboembolism (VTE) Prophylaxis ordered *** VTE Prophylaxis received within 24 hours prior to surgery to 24 hours after surgery *** ***new measures effective with 10/1/2006 discharges
6. Catheter Associated Urinary Tract Infections (CA-UTI) GOAL Reduce and ultimately prevent cases of symptomatic CA-UTI What is symptomatic CA-UTI? Infection-causing symptoms as defined by the CDC s National Health Safety Network (NHSN) in the setting of an indwelling urinary catheter that is in place or has been removed within the past 48 hours
WHY CA-UTI? Most common hospital-acquired infection: 40% of all HAIs > 1 million cases annually (hospitals & nursing homes) 12-25% of all hospitalized patients receive a urinary catheter Half of these found to not have valid indication
Evidence of Success Numerous published studies reporting reductions in CA-UTI rates of 48-81% Use of reminders Nurse-driven protocols Reduction in duration of catheter days The duration of catheterization is the most important risk factor for development of infection. SHEA-IDSA Compendium, October 2008
Preventing CA-UTI 1. Avoid unnecessary urinary catheters 2. Insert using aseptic technique 3. Maintain catheters based on recommended guidelines (daily care) 4. Review catheter necessity daily and remove promptly
1. Avoid unnecessary urinary catheters Studies: 21% of catheters not indicated at insertion 41-58% in place found to be unnecessary Catheters Are uncomfortable for patients Decrease mobility, which may impair recovery and contribute to other complications (e.g., pressure ulcers, deep vein thrombosis) Saint S, Lipsky BA. Preventing catheter-related bacteriuria: Should we? Can we? How? Arch Intern Med. 1999 Apr 26;159(8):800-808. Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995;155:1425-1429.
Indications for Indwelling Urinary Catheters Based on expert guidelines and published literature: Perioperative use for selected surgical procedures Urine output monitoring in critically ill patients Management of acute urinary retention and urinary obstruction Assistance in pressure ulcer healing for incontinent patients As an exception, at patient request to improve comfort (SHEA- IDSA) or for comfort during end-of-life care (CDC)
Avoidance Strategies External condom catheters for appropriate male patients Intermittent catheterization multiple times per day Assessing urinary retention with bladder ultrasound
Changes to Avoid Unnecessary Catheters Develop criteria for appropriate insertion and verify prior to every insertion Empower nurses to contact physicians before insertion if criteria are not met Use a checklist of criteria include this with the insertion kits Determine where most catheters are inserted (probably the ED) and start there
2. Insert urinary catheters using aseptic technique Utilize appropriate hand hygiene practice. Insert catheters using aseptic technique and sterile equipment, specifically using: gloves, a drape, and sponges; sterile or antiseptic solution for cleaning the urethral meatus; and single-use packet of sterile lubricant jelly for insertion. Use as small a catheter as possible that is consistent with proper drainage, to minimize urethral trauma.
Changes to Ensure Consistency of Technique Standard insertion kits with all necessary supplies Include technique in checklist for insertion (along with criteria) Design processes to ensure consistent stock of supplies in needed areas
3. Maintain catheters based on recommended guidelines Maintain a sterile, continuously closed drainage system. Keep catheter properly secured to prevent movement and urethral traction. Keep collection bag below the level of the bladder at all times. Maintain unobstructed urine flow. Empty collection bag regularly, using a separate collecting container for each patient, and avoid allowing the draining spigot to touch the collecting container. Maintain meatal care with routine hygiene (bathing).
Practices to Avoid Irrigating catheters, except in cases of catheter obstruction Disconnecting the catheter from the drainage tubing Replacing catheters routinely (in the absence of obstruction or infection); if the collection system must replaced, use aseptic technique These practices may actually increase the risk of infection and other complications.
4. Daily review of necessity with prompt removal The duration of catheterization is the most important risk factor for development of infection. SHEA-IDSA Compendium, October 2008 74% of hospitals surveyed did not monitor catheter duration. 47% of patient days had no justification for continued catheterization. 41% of the time, physicians were unaware of patients inappropriately catheterized. Saint S, Kowalski. 2008. Jain P, Parada JP.1995.
Daily Review of All Urinary Catheters Determine need for continuation Remove if not indicated Possible strategies: Nursing assessments at every shift, with requirement to contact physician if criteria are not met Nursing protocols for removal of urinary catheters based on criteria Automatic stop orders for 48 to 72 hours after insertion, continuation only when indication is documented in renewal order Reminders in patient records requiring physicians to document indication for continuation of catheter
It s all about the Bundles! Be proactive Function as a multidisciplinary team Be your patients advocate Be a reminder to others Be a positive influence on outcomes Be vigilant on your care
Leadership For North Shore-LIJ, the safety of every patient who is treated at any of our facilities should be guaranteed. As an organization, we must have zero tolerance for infections. Michael Dowling President & CEO North Shore - Long Island Jewish Health System Spring 2005 65
References APIC CA-UTI Elimination Guide www.apic.org/cautiguide
You have completed this module It is required that you take a post assessment after completing this module. Passing score is 100%. Complete the post assessment IHI Quiz which is located on the Quia site 67