Nurses Role in CLABSI Prevention Do no harm Donna Matocha, DNP, MSN, CNRN, VA-BC

Nurses Role in CLABSI Prevention Do no harm Donna Matocha, DNP, MSN, CNRN, VA-BC

DISCLOSURES Employee of Medline Industries, Inc. Opinions expressed are my own and not necessarily representative of Medline Industries, Inc.

Objectives Discuss nursing theory and ethics Examine steps for initiating change Describe a successful change process

The Philosophy & Science of Caring 1 Jean Watson, PhD, RN, AHC-BC, FAAN Art-Humanities-Science Discipline versus Profession Caring is consistent with Nightingale s sense of calling Evidence-Based Practice (EBP) Caring - Outcomes

5 Clinical Ethics 2 Beneficence, Non-maleficence, Justice and Respect for Autonomy Empathy, Compassion, Fidelity, and Integrity Clinical Judgement & Clinical Uncertainty Medical errors Moral distress Healthcare inequities Costs in clinical decisions

6 EBQI Versus Clinical Research Infusion Nurses Society Standards of Practice 3 CDC Guidelines for the Prevention of Intravascular Catheter Related Infections 4 Institute for Healthcare Improvement

7 Holistic Nursing & EBP

ORGANIZATION CHANGE Change theories Change in Healthcare Sustainability Change agent qualities 8

Healthcare Acquired Infections A Meta-Analysis Over 5 million CVCs inserted annually 6 Up to 25% mortality rate 6 Estimated cost of the 5 most common HAIs = $9.8 billion 5 CLABSI ranks 4th and accounts for 18.9% of total cost Per case CLABSI was found to be the most costly = $45,814 MRSA CLABSI = $58,614 + higher LOS 65-70% CLABSI are preventable with current EB interventions

What does this mean to hospitals? 6,7 3% HRRP 2% VBP 6% 1% HACs 10

4/4/2018 Presentation Title Financial Implications 6 For every $100,000 that a hospital spent on safety programs, it realized an average $315,000 savings thanks to fewer infected patients 6 More than 60,000 primary bloodstream infections related to central lntravenous catheters are estimated to occur each year in the U.S., with a fatality rate of 12% or more 8 A study published in JAMA Internal Medicine Journal evaluated data from the last 10 years CRBSIs at 113 hospitals showed: Safety interventions, on average, reduced infection rates by 57% Produced a net savings of $1.85 million per site over three years. Savings came from reduced costs in treating infected patients.

IT IS TIME TO BUILD YOUR TEAM You PICC Team Infection Prevention Physician Champion Nursing Education/Professional Practice Chief Nursing Office Purchasing 1

13 Facilitators & Barriers Facilitators Interdisciplinary approach 10 Empowerment to STOP bad practice 9 Partnership with senior medical & nursing staff on individual units 11 Project leader is credible among peers and role models strict compliance with protocol/checklist and is sincere about the value of the program 11 Barriers Local leader driving change versus centrally lead programs 11 Goals, interest and priorities of the program are misaligned with staff 11 Unsupported hierarchical cultures improvement opportunities often go unrecognized 11 Poor executive leadership 11 Hostile individuals apathy, exasperation and bewilderment 11

Vision, Innovation, Transformation Questions to Ask Does staff fully understand the IHI Bundle and are they compliant? Who reviews your policies? How often are policies reviewed? What evidence supports your policies, procedures and practice? Who does CVC/PICC insertion, education and competency? How often is vascular access education done? Upon hire? Annually? Change in job description? How often is vascular access education done?

15

1 Find your story Compassion Empathy Fidelity Integrity

What Change Looks Like Matocha, D. (2013). Achieving Near-Zero and Zero: Who Said Interventions and Controls Don't Matter?. The Journal of the Association for Vascular Access, 18(3), 157-163.

In the beginning CMS ruling to stop paying for CLABSI Assembled a team Deep dive into practice, policy and products Shared Governance Education and Empowerment 18

19 Variability Education Train People Provide Instructions Provide the Same Materials Kits Develop Process Measure and Utilize to Control Variability

Strategies for the Prevention of Catheter- Related Infections in Adult & Pediatric Patients Guidelines for the Prevention of Intravascular Catheter Related Infections Education, Training & Staffing Recommendations Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections [7 15]. Category IA 20

The Benefit of the Bundle Bundles are intended to test a theory Elements implemented together produce better outcomes Bundles reduce variability and engineer standardized practice

4/4/2018 Presentation Title CVC Maintenance Kits are clinically important in CLABSI reduction 13 Best practice interventions that promote bundles of procedures and technology combined with multimodal strategies of education, training, implementation and dissemination 12 Single use kits are designed to follow the correct procedure sequence every time with every clinician 14

23 Disseminate the Evidence 15 Podium/Oral Presentations Present a poster Publish a paper Write a healthcare policy Nursing grand rounds Local Professional Chapters Hospital/Organizational Professional Committee Meetings Apply for a grant

24 We can t pretend any more that what we do doesn t affect people Courage Compassion Connection Shame Vulnerability

25 In closing Uncertainty Gratitude Celebrate

References 1. Watson, J. (1979). Nursing: The philosophy and science of caring. Nursing administration quarterly, 3(4), 86-87. 2. Jonsen, A. R., Siegler, M., & Winslade, W. J. (2010). Clinical ethics a practical approach to ethical decisions in clinical medicine. McGraw-Hill Medical, New York, NY. 3. Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice (2011) (Vol. 34). 4. O Grady N, Alexander M, Burns L, et al., and Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 [Internet]. 2011 [cited 2013 Feb 28]. Available from: http://www.cdc.gov/hicpac/pdf/guidelines/bsiguidelines-2011.pdf 5. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, Keohane C, Denham CR, Bates DW. Health Care Associated InfectionsA Meta-analysis of Costs and Financial Impact on the US Health Care System. JAMA Intern Med. 2013;173(22):2039 2046. doi:10.1001/jamainternmed.2013.9763 6. Miller, R.D., Eng, T., Kandilov, A., Cromwell, J., McCall, N. (2012). Readmissions due to hospital-acquired conditions: Multivariate model and under-coding analysis. Retrieved from: https://www.cms.gov/medicare/medicare-fee-for-service- Payment/HospitalAcqCond/Downloads/Final-Report-Readmissions.pdf

27 References 7. Bierman, S. (2017). A New Tool for the Vascular Access Toolbox. Infection Control Today, July 7, 2017 8. Lagasse, J Jan 10, 2017. Safeguards, safety programs slash catheter-related bloodstream infections, Cedars-Sinai research shows. Retrieved from: http://www.healthcarefinancenews.com/news/safeguards-safetyprograms-slash-catheter-related-bloodstream-infections-cedars-sinairesearch. 9. Ista, E., van der Hoven, B., Kornelisse, R. F., van der Starre, C., Vos, M. C., Boersma, E., & Helder, O. K. (2016). Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and metaanalysis. The Lancet Infectious Diseases, 16(6), 724-734. 10. Zingg, W., Cartier, V., Inan, C., Touveneau, S., Theriault, M., Gayet-Ageron, A.,... & Walder, B. (2014). Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. PloS one, 9(4), e93898.

28 References 11. Dixon-Woods, M., Leslie, M., Tarrant, C., & Bion, J. (2013). Explaining Matching Michigan: an ethnographic study of a patient safety program. Implementation science, 8(1), 70 12. Zingg, W. & Pittet, D. (2016). Central-line bundles need a multimodal implementation strategy. The Lancet Infectious Diseases, 16, (6), 631 632. 13. Ista, E., van der Hoven, B., Kornelisse, R. F., van der Starre, C., Vos, M. C., Boersma, E., & Helder, O. K. (2016). Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and metaanalysis. The Lancet Infectious Diseases, 16(6), 724-734. 14. Zingg, W., Cartier, V., Inan, C., Touveneau, S., Theriault, M., Gayet-Ageron, A.,... & Walder, B. (2014). Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. PloS one, 9(4), e93898 15. Melnyk, B. M., & Fineout-Overholt, E. (Eds.). (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Lippincott Williams & Wilkins.