Stop Bloodstream Infections Alyssa DeJong RN, BSN, CCRN, Clinical Nurse Educator ICU Lola Twedt RN, BSN, OCN, Clinical Nurse Educator Transplant &Oncology Services What is CUSP? Comprehensive Unit-Based Safety Program 1
Josie King Video 18-month-old Josie King died in 2001 as the result of medical errors at the nation s top ranked hospital, Johns Hopkins Medical Center in Baltimore. Since her death, the King family has worked with Johns Hopkins and other hospitals to make care safer. Medical errors are a leading cause of preventable death in the United States, killing between 44,000 and 98,000 patients in U.S. hospitals every year, more than AIDS, breast cancer or motor vehicle accidents. When we started in Jan 2011 2
South Dakota Hospitals eliminating CLABSI s Avera McKennan Hospital & University Health Center Sioux Falls Avera Sacred Heart Health Services Yankton Sanford USD Medical Center Sioux Falls Sanford Vermillion Medical Center Vermillion St. Mary s Hospital Pierre Winner Regional Healthcare Center Winner 3
Goals Work to eliminate central line associated blood stream infections (CLABSI); state mean <1/1000 catheter days, median 0 Improve safety of culture Learn from one defect per month How are we going to get there? Central Cusp Group ICU CUSP Group 3 East CUSP Group 4
It takes Multidisciplinary Team Work: Central Cusp Committee Members Lanette Diede CUSP Lead Michael Elliott MD CMO Alyssa DeJong RN Co-Chair Lola Twedt RN Co-Chair Aris Assimacopoulos MD Edward Zawada MD Matthew Casey MD Judy Lamphrom, RN I.C. Michael Bauer MD R. Auvenshine MD Thomas Johnson Pharmacy Tami Schnetter RN eicu Ryan Schellpfeffer MD Vinod Parameswaran MD Jill Casanova, RN Director Karen Miller, RN Manager Bethannie Vermeer RN 3E Latonia Moncur MD Michelle Stephens RN Manager Terry Wensing RN ICU Alma Kooistra RN Picc Team Anthony Hericks MD Jenna Westerberg RN Scott Welch CRNA 5
How are we eliminating CLABSI with CUSP? Staff education Accountability Diligence Review of each case that fails CLABSI Definition Central Line-Associated Bloodstream Infection (CLABSI) is a primary bloodstream infection (BSI) in a patient that had a central line within the 48- hour period before the development of the BSI. NOTE: There is no minimum time period that the central line must be in place in order for the BSI to be considered central line associated. 6
Definition : Central Line A vascular infusion device that terminates at or close to the heart or one of the great vessels. The following are considered great vessels Aorta Pulmonary Artery Superior vena cava Inferior vena cava Brachiocephalic veins Internal Jugular veins Subclavian veins External iliac veins Common femoral veins Central Lines Continued Neither the location of the insertion site nor the type of device may be used to determine if a line qualifies as a central line. The device must terminate in one of the great vessels or in or near the heart to qualify as a central line. An introducer is considered a central line. Pacemaker wires and other non-lumened devices Pacemaker wires and other non-lumened devices inserted into central blood vessels or the heart are not considered central lines, because fluids are not infused, pushed, nor withdrawn through such devices. 7
Types of Central Lines Temporary - A central line that is non- tunneled. Includes: Central line, PICC, Jugular line Permanent Includes Tunneled catheters including hickmans, apheresis, trifusion and certain dialysis catheters. Implanted catheters (including portacaths). Laboratory Confirmed Bloodstream Infection (LCBI) LCBI Criterion 1 Patient has a recognized pathogen cultured from one or more blood cultures And Organism cultured from blood is not related to an infection at another site. 8
Notes about Criterion 1 The phrase, one or more blood cultures means that at least one bottle from a blood draw is reported by the laboratory as having grown organisms. Recognized pathogen does not include organisms considered to be common skin contaminants Examples of recognized pathogens: S. aureus Enterococcus spp. E.coli Pseudomonas spp. Klebsiella spp. Candida spp. Laboratory - Confirmed Bloodstream Infection (LCBI) LCBI Criterion 2 Patient has a least one of the following signs or symptoms: fever (>38C), chills, or hypotension And Signs and symptoms and positive laboratory results are not related to another site And Common Skin Contaminant is cultured from two or more blood cultures on separate occasions. 9
Blood Culture Specimen Collection Ideally, blood specimens for culture should be obtained from two to four blood draws from separate venipuncture sites, not through the vascular catheter. These blood cultures should be performed simultaneously or over a very short period of time, i.e. within a few hours. Unit Collaboration Transfers to Facility Standards: ICU and Transplant & Oncology Services team up. Open dialogue Learn from each other Collaboration with other departments GOAL ALWAYS: PATIENT SAFETY! 10
Current ICU Practices to Eliminate CLBSI Portable central line cart with all necessary items immediately available Line placement with maximal barrier precautions Central Line Insertion Checklists completed by bedside staff Avoid femoral lines if possible Chlorhexadine for insertion and maintenance Dressing changes every Thursday Resource RN assessment of central line sites Multidisciplinary Rounds that involve review of central lines Remove unnecessary lines ASAP Educate Staff!!! ICU Central-Line Blood Stream Infections Fiscal Year 2012 Central Line-Associated Blood Stream Infection Rates 40.0 35.0 35.09 12/1/10: CL Dressing RATE per 1000 Central Line Days 30.0 25.0 20.0 15.0 10.00 5.0 791 7.91 6.04 4.02 9/09: Began S b th H b 3.91 5.24 13.16 24.69 3.57 3.40 3.97 4.93 858 8.58 4.29 3.37 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.0 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 RATE per 1000 Central Line Days UCL (2 STD) Linear (RATE per 1000 Central Line Days) 11
TITLE HERE Current 3East Practices to Eliminate CLBSI Staff Involvement and Commitment Patient Education Hand hygiene and scrub the hub audits Diligent bedside care of the line with assessment every 4 hours. Chlorhexidine usage for insertion and maintenance 2 Person Sterile venous access device dressing (Tegrederm CHG) changes every Thursday. Maxguard caps PICC Line placement with maximal barrier precautions and checklist completion Physician rounding with primary care RN review of venous access devices Remove unnecessary lines ASAP 12
Collaboration is Key Patient transfers between 3East and ICU Bedside Handoff Communication Standardization of care Criteria for Maxgaurd cap usage: WBC< 1000 (immunocompromised) Chemotherapy patient t Bone Marrow Transplant patient Solid Organ Transplant patient DID YOU KNOW: Avera McKennan has changed all IV Policies SCRUB THE HUB For 15 Seconds. Every patient every time.. Watch the clock for 15 Seconds. Scrub vigorously each time! 13
3 East Central-Line Blood Stream Infections Fiscal Year 2012 Central Line-Associated Blood Stream Infection Rates 9/09: Began Scrub the 20.0 6/10: VAD line identification 1/2011 Joined the SD CUSP Project Hub Audits education 18.0 8/26/10-10/1/10: Pilot Project on changing all VAD dressings on Thursdays 16.0 RATE per 1000 Central Line Days 14.0 12.0 10.0 8.0 6.0 459 4.59 8.47 5.79 4/2011: 3E w ill trial the VAD Max Guard Clear (antimicrobial) cap on imm Will evaluate for flush ease - visualization of blood and use ease. 5.84 465 4.65 422 4.22 4.0 2.0 2.92 1.72 1.79 3.14 1.54 1.67 1.83 1.96 1.96 2.00 2.18 1.69 0.00 0.00 0.00 0.00 0.00 0.00 0.0 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 RATE per 1000 Central Line Days UCL (2 STD) Linear (RATE per 1000 Central Line Days) TITLE HERE 14
Time Line 2 Years (commitment with study) Unit teams determine what is needed Meet with Central Team on a monthly basis CUSP Goals Transparent with Data Identify Safety Defects Evaluation Tool for root cause analysis Learn from our Mistakes (EBP) Team Work 15
Learning from Mistakes What happened? Why did it happen (system lense) What could you do to reduce risk How do you know risk was reduced Create policy/process Ensure staff know policy Evaluate if policy is used correctly Leading Change Technical work Work for which there is know science Eid Evidence and measures Adaptive work Work for which there is no science Requires changes in values attitudes belief Need to get both technical and adaptive work right Adaptive work is usually why programs falter 16
TITLE HERE How will your next patient in your unit or clinic area be harmed? 17
Do we believe we can have zero line infections? The state of Michigan has done it! The state of South Dakota is doing it too! CUSP, in combination with evidence based practice, has led to dramatically reduced CLABSI rates at both Johns Hopkins and in the State of Michigan. 2008 Avera McKennan 2008 Avera McKennan 2010 Avera McKennan 18