NewYork-Presbyterian Morgan Stanley Children s Hospital Columbia University Medical Center

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1 NewYork-Presbyterian Morgan Stanley Children s Hospital Columbia University Medical Center

2 Clean It Like You Mean It! A 3-ICU Collaboration on Central Line-Associated Bloodstream Infection Prevention Svetlana Streltsova Clinical Nurse III/RN, MSN, CCRN Kathy Lee Clinical Nurse II/RN, BSN, CCRN Regan Morimoto Clinical Nurse II/RN, CCRN Anisha Soman Clinical Nurse I/RN, MSN Brian Harding (Sep 2013-Jul 2014) Clinical Nurse I/RN, BSN, CCRN

3 NewYork-Presbyterian Morgan Stanley Children s Hospital Columbia University Medical Center

4 Problem Statement Do continuous education sessions, central line maintenance protocol, and weekly surveillance by nurse champions reduce the incidence of central line-associated bloodstream infections (CLABSIs) in neonatal, pediatric, and pediatric cardiac intensive care settings?

5 Purpose The Clean It Like You Mean It campaign is a collaborative initiative between 3 ICUs The team uses evidence-based best practices to reduce CLABSIs The purpose of the project is to prepare hospital nurses with the knowledge, skills, and practice guidelines to reduce CLABSIs and maintain a low incidence

6 Goals Decrease morbidity associated with CLABSIs in our patient population Improve patient outcomes Reinforce and improve best practices Decrease overall hospital cost Decrease hospital length of stay associated with CLABSI Reduce CLABSI incidence by 50% in the 3 units

7 Goals Each unit will remain below NYP s 2014 standardized infection ratio (SIR) goal The NICU, PICU, and PCICU will each work to remain at or below the 2013 SIR for their unit

8 Plan-Do-Study-Act Methodology Act Plan Study Do Testing Practice Change to Prevent CLABSIs

9 Plan-Do-Study-Act Plan Logic Model Current practice Short-term goals Long-term goals Timeline for intervention implementation Surveillance Data collection (past, current, and goal) Data dissemination

10 Plan-Do-Study-Act Do Scrub the Hub hangtags on all IV poles CLABSI prevention posters in all 3 units Continued educational strategies: Education and practice validation through return demonstration Central line maintenance and care Dressing changes Central Line changes Scrubbing the hub Chlorhexidine (CHG) baths Hand hygiene

11 Plan-Do-Study-Act Do Use of alcohol-impregnated caps on needleless ports Timely removal of central lines when no longer necessary CLABSI prevention education in groups and 1-on-1 Team conducted weekly central line surveillance: Assessing sites Assessing central lines Dressings Length of time the central line has been in place Real-time maintenance care

12 CLABSI Carnival Kickoff January/February 2014

13 Nurses Week 100+ Nurses Attended (May 2014) CLABSI Awareness Prevention Table Hands-on demonstration of Scrub the Hub Trivia questions on central line care Review of central line dressings and changes Education and use of alcohol-impregnated caps on needleless ports Review of central line change policy and central line care

14

15 Plan-Do-Study-Act Study Nurse champion team analyzed how well nurses are sustaining evidence-based practice in central line care Best practice in accessing central lines, dressing changes, use of alcohol-impregnated caps on needleless ports, and CHG baths

16 Plan-Do-Study-Act Study Weekly central line surveillance 32 weeks of surveillance 300+ central line assessments Central line appearance, needleless caps, central line sites, and dressings CLABSI data/statistics compared to 2013

17 Line Saturated with Blood Caps saturated with Blood Inappropriate Needleless Caps Reddened Central Line Sites Central Line Sites Leaking/Bleeding Dressings Loose, Soiled, Overdue # of Assessments Central Line Surveillance Based on 309 Central Line Assessments

18 MSCHONY ICU CLABSI Data 2012 Data by ICU Unit (19 CLABSIs) The hospital s overall SIR for 2012 was 0.60 Infection Protection & Control SIR goal of 0.75 Unit CLABSIs SIR NICU PICU PCICU

19 MSCHONY ICU CLABSI Data 2013 Data by ICU Unit (17 CLABSIs) The hospital s overall SIR for 2013 was 0.58 IP&C SIR goal of 0.65 Unit CLABSIs SIR CL-Days NICU ,430 PICU ,072 PCICU ,572

20 CLABSI Data With CSI Intervention CLABSI Data: January 2014 September NICU CLABSIs 5,221 central line days (CL-days) September 2013: 4 CLABSIs with 5,396 CL-days CLABSI rate 2013: 0.74 per 1,000 CL-days CLABSI rate 2014: 1.15 per 1,000 CL-days 55% increase in CLABSI rate Patients by Grams CLABSIs <= , ,001-1, ,501-2,500 1 > 2,500 2

21 Rate per 1,000 CL-Days MSCHONY 2013 NICU CLABSI Rates g g g g >2500 g MSCHONY NICU National Healthcare Safety Network (NHSN) BENCHMARK

22 CLABSI Data With CSI Intervention CLABSI Data: January 2014 September PICU CLABSIs 2,209 CL-days September 2013: 4 CLABSIs with 2,306 CL-days CLABSI rate 2013: 1.73 per 1,000 CL-days CLABSI rate 2014: 1.36 per 1,000 CL-days 21% decrease in CLABSI rate

23 CLABSI Data With CSI Intervention CLABSI Data: January 2014 September PCICU CLABSIs 2,427 CL-days September 2013: 4 CLABSIs with 2,722 CL-days CLABSI rate 2013: 1.47 per 1,000 CL-days CLABSI rate 2014: 0.00 per 1,000 CL-days 100% decrease in CLABSI rate

24 Rate per 1,000 CL-Days MSCHONY 2013 ICU CLABSI Rates PICU PCICU 2013 NHSN Benchmark

25 # CLABSIs MSCHONY ICU CLABSIs by Unit NICU PICU PCICU

26 Length of Stay Unit * NICU PICU PCICU *January to August data

27 Fiscal Impact Projected Project Savings Estimated cost per CLABSI infection ranges from $6,000 $29,000 CMS average: $12,378 MSCHONY spent anywhere from $102,000 $493,000 for ICU CLABSIs in 2013 alone At least a 50% reduction will save the hospital as much as $250,000

28 Fiscal Impact Actual Savings 2013 ICU CLABSIs = 17 ICU CLABSIs January 2013 September 2013 = 12 ICU CLABSIs January 2014 September 2014 = 9 As much as $87,000 saved in CLABSI prevention to date Using the CMS average of $12,378/CLABSI translates to a savings of $37,134 (over 9 months) Projected annual savings: $99,024 (assuming 9 CLABSIs in 2014)

29 Cost of a Child Without a CLABSI: IMMEASURABLE

30 CSI Budget Total dollars spent: $ % 12% 25% 25% 22% Posters Educational Material Team Shirts Staff Gift Giveaway Food Printed Water Bottles 7%

31 Barriers/Lessons Learned NICU Inadequate number of CLABSI champions identified early in the initiative to support the volume of patients and the unit staff Need increased education efforts on central line care and maintenance Need increased central venous line (CVL) surveillance in the unit

32 Barriers/Lessons Learned PICU Nurse and physician buy-in Protected time for education and validation Significant percentage of rotating staff (RN/MD) Practice deviation from policy Barriers encountered with interdisciplinary team collaboration situation has improved

33 Barriers/Lessons Learned PCICU Protected time for education and practice validation, data collection, and data dissemination Barriers encountered with interdisciplinary team collaboration situation has improved Early staff buy-in, ownership, and practice collaboration improve outcomes Surveillance is KEY to sustaining best practice

34 Sustainability Continue weekly surveillance Frequent huddles on infection prevention, best practice, and barriers to following evidence-based practice Protocol changes per evidence-based literature Nurse champions identifying unit MVPs in CLABSI prevention Daily CLABSI champions available in units to assist and troubleshoot with central line maintenance and care

35 Sustainability Continue education and practice validation for nursing and medical staff alike Identify new medical products to support our initiative in CLABSI prevention Implement universal gloving Initiate parent education on CLABSI prevention Roll out initiative of CLABSI prevention and CHG baths to other units Disseminate data to staff to maintain awareness and compliance

36 Conclusions CLABSIs are preventable Nurses empowered in CLABSI prevention on a daily basis Continued education, surveillance, and practice validation improve adherence to proper central line insertion technique, maintenance, and care Recruit CLABSI champions on your unit to assist and adhere to best practices

37 Thank You Kari Mastro, MSN, RN, NEA-BC, VP Nursing, Patient Care Services Margaret Quinn, MPH, RN, Senior Director Nursing, Director of Quality and Compliance Donna D. Johnson, MS, MBA, NE-BC, CPHQ, Director of Nursing, Critical Care Fern Butler, RN, Director of Women s Health and Neonatal Services Maria Esperanza L. Estilo, MSN, Patient Care Director, Pediatric Cardiac Intensive Care Andrea Hughie, MSN, Patient Care Director, Pediatric ICU Ramon Abuedo, MSN, Patient Care Director, Neonatal ICU Eunice Clark, BSN, RN, CCRN, Project Logo Contributor Nathan Chang, BSN, RN, CCRN, Creative Artist

38 Our sincere gratitude to the following individuals for all their support: Myrlene Madelon, RN, MSN, CCRN Internal Coach Marian Altman, RN, MS, CNS-BC, ANP CSI Instructor Debbie Brinker, RN, MSN, CNS CSI Instructor

39 STOP CLABSIs

40 References Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R. Infusion Nursing: An Evidence-Based Approach. St. Louis, MO: Saunders; Blot K, Bergs J, Vogelaers D, Blot S, Vandijck D. Prevention of central line-associated bloodstream infections through quality improvement interventions: a systematic review and meta-analysis. Clin Infect Dis. 2014;Epub ahead of print. Centers for Disease Control. Guidelines for the prevention of intravascular catheter-related infections Accessed October 6, Central Venous Catheters: Maintenance Care. NewYork Presbyterian Hospital Procedure Dudeck MA, Weiner LM, Allen-Bridson K, et al. National Healthcare Safety Network (NHSN) report, data summary for 2012, Device-associated module. Am J Infect Control. 2013;41(12): Hooven TA, Polin RA. Healthcare-associated infections in the hospitalized neonate: a review. Early Hum Dev. 2014;90(Suppl 1):S4-S6.

41 References The Joint Commission. Preventing central line-associated bloodstream infections: a global challenge, a global perspective Accessed October 6, Miller SE, Maragakis LL. Central line-associated bloodstream infection prevention. Curr Opin Infect Dis. 2012;25(4): Research Triangle Institute for Center for Medicare & Medicaid Services. Analysis report: Estimating the incremental costs of hospital-acquired conditions (HACs) Payment/HospitalAcqCond/index.html. Accessed April 1, (Click Incremental Updated Cost Report.) Smith JS, Kirksey KM, Becker H, Brown A. Autonomy and self-efficacy as influencing factors in nurses behavioral intentions to disinfect needleless intravenous systems. J Infus Nurs. 2011;34(3): Yin J, Schweizer ML, Herwaldt LA, Pottinger JM, Perencevich EN. Benefits of universal gloving on hospital-acquired infections in acute care pediatric units. Pediatrics. 2013;131(5):e1515- e1520.

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