Conference Report: 3M IV Global Leadership Summit Theme -Transforming Leaders: Transforming Care Catharine O Hara RN MN

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1 Conference Report: 3M IV Global Leadership Summit Theme -Transforming Leaders: Transforming Care Catharine O Hara RN MN Catharine O Hara, Clinical Nurse Specialist (Lead), Intravenous and Related Therapies, employed at MidCentral District Health Board was the successful applicant of the 3M scholarship and attended the 3M Global IV Leadership conference in St Paul, Minneapolis and the Infusion Nurses Society Conference in Charlotte, North Carolina, USA. The representatives attending from the many countries provided a cultural exchange on how they are transforming care in their healthcare facility. Prior to the 3-day summit I presented to the 3M staff on a transformational moment in my workplace. My topic focused on setting up a Nurse-Led PICC insertion service in the Medical Imaging department. Background: PICCs inserted by 1 st year medical staff Education facilitated by Clinical Nurse Specialist IV Therapy Product Supplier provided education Nurse-Led PICC service started with Hospital in the Home Service Reliant on the nurse employed Requires a Service/Team approach Transformational moment implementing ultrasound skills for nurses Transformational moment tactics: Tactic 1 meeting with Medical Imaging (MI) Staff two MI nurses to learn PICC insertion Tactic 2 Radiologist support & provided Ultrasound education to 5 nurses Tactic 3 Advertise the new PICC insertion service Key Success Factors in Transforming Care Key Factor 1 - Team approach Key Factor 2 - Buy-in from Medical Imaging Physician Champion Key Factor 3 - Referral process utilising current MI referral form Key Factor 4 - Planning & support for data Recommendation: Utilise W. Edward Deming s PDSA cycle earlier to implement change. 1

2 The M Global IV Leadership Summit was hosted in partnership with BD in St Paul, Minnesota. The summit sessions were developed with progressive themes over three days, reviewing principles of behaviour change and risk management that lead to successful change, methods of surveillance, and the tools available to drive successful change and adopting new technology in resource constraint environments. It is in our hands to make a difference. Day One The first speaker, Russ Nassof presented on the components for establishing a culture of safety and the importance to find a commonality by identifying the issues, risk management exposure point, solution/action to make change, and behaviour change required and for whom. A case study was presented which made this a valuable interactive session to manage the risks effectively. The 5 critical risk exposure points for device associate infections are: 1. Education/competency - based on standards and organisation policies (training is not competency) 2. Insertion hand hygiene, site preparation, patient factors 3. Maintenance monitor, dressing and cap changes, flushing 4. Responding to adverse events site assessment, removal of device 5. Incorporating technology securement devices, antimicrobial dressings The six key elements to reduce disparity and form the foundation to establish change are I.E.I.E.I.E.: Identification of the problem issues of product or practice Education competency, training, multi-disciplinary Improvement - simple, easily attainable and must bring value Embed checklists, bundles, documentation Innovation continuous evaluation as may create new area of risk Empathise communicate and apologise when mistakes are made Jack Stoltzfus described the impact and assumptions of change. The only things you can t avoid are death and taxes oh and change. You can be a victim or a manager of change. The processes involved in change, which is used for Quit programmes, include Prochaska s five stages of change: Pre-contemplation Contemplation Preparation Action Maintenance 2

3 However, the emotional process such as Kubler-Ross method and neuroscience of change is often neglected. Change may occur after one of those oops moments. In the workplace we often provide Feedback - what you did, when it may be best to provide Feed-forward what to do. To master change requires using your mind, such as the C.L.A.P. (s) Model : C= Calm down, cool off, count to 10 (slow breathing, relaxation, meditation), L= Labeling your emotional reactions, A= Analysis your options/choices and refuse to be the victim P= Plan your attack - focusing on solutions and not the problem (s) Start now Professor Knoke described the value of social networking to improve performance. Understanding how to create social capital networks in infusion teams could improve both individual and team performances. We should strive to practice what we preach by cultivating connections to people and organisations that control access to important information, knowledge, and social resources. Pay it backward and forward, you increase your chances of access to resources by always being willing to help those in need. Remember: It s not what you know, nor whom you know, but whom you know who knows you don t know and is willing to tell you so. Day Two Making the case for health economics as applied in Mexico, Dr. Rafael Santana Mondragon, discussed the challenges of maintaining a health care system with increasing costs. Health economics is about choices and evaluation could it work (efficacy), does it work (effectiveness), and does it work well (efficiency)? An incremental cost-effectiveness ratio is applied to establish health benefits for Mexico based on quality-adjusted life years. Surveillance methods and preventing catheter-related blood stream infections presentations. 1. Surveillance requires developing proper data to track infections according to Dr. John Jernigan, director of Healthcare Acquired Infections (HAI) prevention research and evaluation of the Centers for Disease Control and Prevention (CDC). Surveillance is complicated due to complex definitions, and data is obtained from a variety of systems, such as, laboratory, admissions, clinical assessments, and multiple staff members requiring subjective interpretation. Biased search was demonstrated with the case presentations and the risk of using pre-selected conclusion. To prevent bias requires making surveillance more objective by using a computer algorithm to ensure reliability. The future of HAI surveillance is likely to expand with electronic data collection and algorithmic detection to reduce variability across 2. Dr. Ghinwa Dumyati presented on Central line-associated bloodstream infection (CLABSI) surveillance and prevention outside the ICU. Surveillance of CLABSI is very labour intensive if data collected daily and suggested a practical measure to monitor CLABSI by estimating central line-days and focusing on maintenance of central lines. In Rochester, they collaborated with 6 other hospitals and completed random audits over 1 month with two staff reviewing all CLABSI for reliability using a 4-stage approach: 3

4 Stage 1 Stage 2 Stage 3 Stage 4 Baseline data Evaluations of Interventions Effect Collection of line and patient days to Policies Procedures and Quarterly feedback of CLABSI rates generate Device Use Ratio (DUR) Collection of CLABSI events Generation of baseline CLABSI rates Review each hospital CVC policies. Survey nursing knowledge regarding line insertion and care. Creation & Introduction of CVC maintenance bundle. Education of nursing staff of proper line maintenance Audits of line care and maintenance of Intervention Assess the effect of feedback and education on the rate of CLABSI The CDC-National healthcare safety network (NHSN) CLABSI surveillance definitions were utilized, available from Once a week (midweek), collection of line-days and patient-days was collated to calculate a Device Use Ratio (DUR). DUR = Number of patients with central lines Number of patients on the unit The monthly estimated line-days = DUR x monthly patient-days. If less than 100 line days is calculated then this method is not recommended. Recommend targeting wards/areas with high central line use. Compliance in collecting data is enhanced when assigned to a specific staff member, and using electronic reminders. To improve compliance a poster was created for display in the wards: Central Line Maintenance Bundle Hand Hygiene Wash hands with soap and water or alcohol based hand rub before accessing or changing dressing (IB) Needleless access device Clean before accessing with Chlorhexidine, iodine or 70% alcohol Using twisting motion for at least 15 sec (IA) Change aseptically no more frequently than every 72 hours and with tubing change (II) Dressing Change Assess dressing integrity, change if loose or soiled (IB) Change transparent dressing every 7 days (IB) Change Gauze dressing every 2 days (II) Clean site with >0.5% chlorhexidine/alcohol for 30 seconds (IA) Administration Sets Change no more frequently than every 96 hours but at least every 7 days (IA) Change every 24 hours for TPN, containing lipids & blood and after each chemotherapy infusion * (IB) 4

5 CVC need assessment Assess central line necessity daily* Promptly remove CVC when no longer necessary (IA) Education was the major focus as nurses know the correct procedures but don t do it. They identified the gaps to create a self-directed online education module, which you can access for free: This was a 3-year multidisciplinary team project; focus was not just on education, also checked competency and giving rewards. The challenges were overcome with unit nurses and nurse leaders conducting demonstrations of proper technique, one-on-one training, and monitoring processes. Nurses suggested additions to the maintenance bundle use of additional products, and enhancing compliance with proper central line flushing. 3. Dr. Regina Nailon, clinical nurse researcher, provided a strategic direction for surveillance outside the hospital, monitoring home health outcomes. Monitoring of CVC line care processes and outcomes after leaving hospital is very difficult. Standardising CVC care in the outpatient realm: care from hospital to home was achieved by engaging stakeholders, gathering evidence of systems performance, examining the lessons learned to develop recommendations. In God we trust, all others bring data W Edward Deming Data was collated on number of patients on the service with CVC in place receiving CVC care from the agency. The data was imported into Excel spreadsheets: BSI rate /100 device days, occlusion rates/1000device days and the ratio of fibrinolytic doses/occlusion events. Quarterly benchmark reports were generated on agency performance compared to aggregated mean. No agency identifiers were exchanged as labeled Agency A F. Home healthcare outcomes are measurable and focus on specifics of CVC care to better drive quality improvement. For example, this research identified the need to develop a prevention of CVC occlusions. Next step is a patient-centred outcomes research - Day in the life of a line as in the Nebraska region 87% of care is delivered in the home. 4. Epidemiology of HAI internationally was presented by Dr. Victor Rosenthal, which highlighted the burden of endemic health care-associated infection in high-income countries and the variances for developing countries. 5. Lynn Hadaway reviewed the literature on short peripheral IV catheters and infection rates, as there are many unanswered questions about outcomes with their use and very little attention to infection risks. Many conflicting approaches were identified, such as, CLABSI is a surveillance definition for central associated bloodstream infection in comparison to CRBSI (catheter-related blood stream infection) is a diagnostic term for all catheters. Three types of infections identified: mechanical, bacterial, and chemical. The most likely mechanisms of peripheral catheter BSI include: a. Colonization of the vascular catheter tract b. Biofilm formation c. Occurs during insertion and manipulation d. No evidence on the connection between thrombophlebitis and BSI 5

6 Clinical Issues identified: o Catheter design: Ported catheters = 27% incidence of infection o Skin Antisepsis: no studies support circular motion, very few studies provided information on the agents, application technique, or time or drying time. NEW if palpate must use sterile gloves. o Skill of inserters: phlebitis rates of Emergency department nurses 3.7% versus IV nurses 2.1%. o Predisposition to phlebitis: higher rates if more than one catheter site o Vein visualisation technology: Infrared light no infections reported. Ultrasound two studies identified infections. o Catheter stablisation: multiple studies on stabilization but no data on type of infections or unplanned re-cannulations. o Catheter removal: replace when clinically indicated for adults and paediatrics or on any complaint of pain or discomfort. Decision to replace peripheral catheter should be based on: assessment of patient s condition, access site, skin and vein integrity, length and type of prescribed therapy, venue of care, integrity and patency of catheter, dressing and stablisation device used. We were provided with a case scenario at the end of day two, utilising the presentations. This activity had the participants working in groups and networking with others. This very interactive session assisted the participants to embed the knowledge learnt on day one. Day Three Dr Steven Gordon recommended that Striving for Zero: challenges and opportunities in infection prevention is achievable by moving from treating illness to promoting wellness. Care transformation is essential in the current health care reform environment. Preventing CRBSI is by: Optimizing insertion central line bundle, Maintenance bundle with daily attention to detail and situational awareness by removal of the line as soon as it is not needed. Change is a process not an event. Dietary and lifestyle changes by the population are need to pivot towards wellness as 75 % of illness is due to lifestyle. Getting to zero infection rates is achievable as all events are 100% preventable. Dr Mervyn Mer presentation Transformed Leaders: Transformed care with his passionate presentation on Pipe Practice: provenance, preventing problems and principles. The incidence of mechanical complications after > 3 insertion attempts is 6 times the rate after 1 attempt. Seek help if unable to insert after 3 attempts. Avoid cutting the skin, and use ultrasound guidance to improve insertion rates especially for internal jugular (IJ) attempts. Always check CXR post IJ/subclavian vein insertion. An early marker for identifying catheterrelated sepsis is by fundoscopy, in conjunction with blood cultures from the catheter and a peripheral site. Avoid use of polymixin-neomycin-bactracin ointments at the entry site as increases the risk of fungal colonization and infection. How the catheter is placed and looked after will prevent complications. 6

7 CRBSI C Chlorhexidine-alcohol skin antisepsis R Remove unnecessary lines B Barrier precautions maximum S Site selection I Infection prevention & control (preparation, insertion, maintenance), importance of hand hygiene The Ps: Principles are non-negotiable, Patience it takes time to change practice, Practice is improved with experience, and Passion is linked to your talent to make a difference. It is in your hands to make a difference, to make this place a better place by preventing complications of CVCs. My transformational moment at the summit was hearing the presentations from global leaders and the international networking. It s a small world when the first person I met was Judy Smith, the keynote speaker at IVNNZ Inc conference. I wish to thank 3M and IVNNZ Inc. for awarding me the 3M Global I.V. Leadership scholarship and MidCentral DHB for supporting my attendance. 7