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CLABSI PreventionTHE PLANReview base line data and look for trendsUnits of occurrenceFrequency of occurrence (per month, per year)Type of line associated with the infectionTime from insertion to infection (per SIA review)If infection occurred in <7 days, be sure to consider insertion as a possible factor. If > 7 days insertion unlikely a factor. Compare outcomes to facility expectations, published literature and possibly other local like HC facilitiesMake sure comparisons are ones that team members support. If the source is not respected, the conclusions from the comparisons won’t be respected.Review best practice guidelinesJoint Commission - see specifically ?section 07.04.01? - CDC (Centers for Disease Control) (category 1A and 1B citable by JC)’s Hopkins?-Peter Provonost and Michigan Keystone – includes checklist examples – Institute for Healthcare Improvement – ? ?(The Society for Healthcare Epidemiology of America) ?(The Society for Healthcare Epidemiology of America) (2014 update)National Kidney Foundation (for management of temporary dialysis catheters), Richard. A Performance Improvement Initiative to Determine the Impact of Increasing the Time Interval Between Changing Centrally Placed Intravascular Catheters. Journal of Burn Care and Research 2014; 35:143-147Infusion Nursing Standards of Practice. Journal of Infusion Nursing 2011, Vol 34. International Society for Burn PatientsInfection Control in Burn Patients , JF. Dressing disruption is a major risk factor for catheter-related infections. Crit Care Med 2012; 40:1707-1714Review current organizational practicesHow does staff know about the expectations? Is it in a policy, or is it something that is taught with variety or assumed to be known when arriving? Have key medical Team Leaders seek out subspecialty best practices (ex Medical Director lead to work with renal experts). This may help find other specialty best practices to consider. Review onboardingHow are nursing staff trained to organizational expectations (lecture, return demo, etc)How are staff MD’s trained to organizational expectationsHow are residents and students trained to organizational expectationsAssemble Team(s)Based on findings from baseline data, best practice, and current organizational practice, determines who needs to be on the improvement team. Consider who in the organization stands to be affected by the changes, and where opportunity lays in standardization of practices across the institution -even in areas that may not currently appear to have issues. Participants respond to executive leadership participation. Medical directors and unit managers level of participation changed when the CEO met with the group and clearly outlined his expectations of the workgroup.Select Project Team Leaders:ICU DirectorOperating Room DirectorInfection Prevention DirectorSICU Medical DirectorMICU Medical DirectorConsider service lines and area of influence. Do not rely on the director of one service line to have influence over another service line. If the team is too large for one group, divide teams up and determine the subgroup goals, actions, and levels of authority.Steering Committee Team Members:Infection Prevention and Infectious Disease PhysicianMICU Nurse ManagerSICU Nurse ManagerPeds Nurse Manager and Peds Medical DirectorBurn Nurse Manager and Burn Medical DirectorED Nurse Manager and ED Lead PhysicianAnesthesia – MDA and CRNAInterventional RadiologistDialysis PhysicianNursing IV Team LeadOffice of the Medical DirectorQuality Staff – Medical and LEANElectronic Health Record developers and report writersWe didn’t have these, but in retrospect may have benefited from:Residents (the ones who are actually putting in the line)Supply ChainDetermine early on what practice care areas have “exceptions”Are the exceptions the preference of staff, or are the exceptions supported by literature and scientific evidence. Determine what is considered a successTargets and goal options: state, federal , institutional, etcExample: Minnesota State Action Plan to Prevent Healthcare-Associated InfectionsNational Action Plan to Prevent Health Care-Associated Infections: Road Map to EliminationDetermine what will be measurableConsider important process measures as a means of sustaining change and maintenance of best practices. Determine which outcomes measures should be used. Define standard work for who does the measuring and how to make the measuring most effectiveDevelop a process to measure practices and/or outcomes that may be required by external agencies. Set reporting frequencyDetermine TimelineFrequency of meetings, how decisions are to be made, who gets to make the decisions, how is this communicated, what is the final goal; keep people aware of the scope of the project, set ground rulesDetermine who and how to keep executive leadership up to date and when to reach out if roadblocks occurDetermine who keeps record of plan and activitiesSelect a person who is knowledgeable in the subject matter:keep noteswrite minutesupdate timelineset agendasConsider other literature that will help providers champion the best practiceDo spend time discussing with the providers what their current practice is, but at the same time discuss with them what it would take to get them to the best practices. It will confound issues if time is spent discussing what is thought to be best practice. Examples: JAMA 2009. Pittet. CLABSI Prevention beyond the ChecklistNEJM 2006 Provonost. CLABSI PreventionInt J Nurs Stud. 2007 Nov;44(8):1324-33. Tsuchida T, The effectiveness of a nurse-initiated intervention to reduce catheter-associated bloodstream infections in an urban acute hospital: an intervention study with before and after comparison.Crit Care Med. 2004 Oct;32(10):2014-20. Berenholtz SM. Eliminating catheter-related bloodstream infections in the intensive care unit.TOOLS:Call To Action Burning platform summaryMeeting agenda templateAction plan templateBest practice summary templatesBest practices/Policy (DO)Burn unit exceptionsInsertion and duration of CVC in burn patients. Limited data is available at this time for the management of burn patients. HCMC practice, based loosely on Shriner’s practice: Place central line, change over a guide wire @day 5; change site at day 10. (INFECTION CONTROL IN BURN PATIENTS Author: Joan Weber, RN, BSN, CIC Infection Control Coordinator, Shriners Burns Hospital, Boston, Massachusetts)Depending on location of line and patient burn surfaces, established and preferred dressing change intervals may not be feasible. Develop a plan for managing the maintenance of these lines. Ensure that staff is familiar with separate process. NICU specificsReview unique requirements for NICU related to UVC and UAC lines, PICC placement location best practices, alternatives to CHG use, prepping the port. Dialysis practicesContracted with Davita for dialysis services and found that Davita practice did not mirror HCMC policy. Davita policy was to change dressings at every dialysis run and frequently using gauze dressing. Worked with Davita leadership to align dressing change frequency and methods to that of HCMC and established best practices. Discovered that larger Biopatch was not onsite for dialysis lines. Made the larger size a storeroom item for dialysis cathetersDiscovered HCMC practices were not standard to the KDOQI guidelines.Unauthorized access. Multiple reports of unauthorized dialysis catheter access. KDOQI guidelines limit access outside of dialysis for emergent use only or with a Renal order for use. Added this to the policy and training. Needless connectors were not in use for dialysis lines, only end caps only were being used between runs. Explored opportunities and found that Tego connectors (a dialysis line needleless connector) were standard in the dialysis community. Worked with MICU staff and Davita staff to bring in connectors and train staff for use. Needed to take into consideration MICU and other staff performing CRRT at HCMC.Discovered Surgical Services did not have all of the best practice supplies for dialysis catheters. Did not have Tego connectors and did not have larger Biopatch. Nursing staff in surgical services needed training on accessing dialysis lines. OrdersNeed order for use for nursing practice. How do the orders address cares? Should incorporate other activities directly surrounding placement such as radiology for verification of placement. Plan what orders are needed if patient comes in with an existing line. Determine if Renal approves use of dialysis lines for routine blood draws and other fluid administration in nonemergent situations. Need to consider how orders flow throughout the organization. How do central lines orders differ for nontunnel vs tunneled catheters placed in the OR.Line selectionWhen to move to tunneled line? Literature suggests 3 weeks. How to make this happen?What type of line is best practice – PICC vs PIV, vs tunneled, etc. To become the policy supporting documentInsertionEnsure there is an insertion checklistCreated an insertion checklist after review of existing checklists from institutions that were successful then modified with Steering Team agreement Start with paper and trial in one area before expanding or modifying. This may take several revisions to determine final productDetermine who can be the insertion observerDetermine where the blank checklists are to be keptDetermine what happens with completed checklists Determine criteria for site selectionWork with best practice and needs of a medical teaching facility for recommendations. CVC kitsEvaluate current supplies to ensure that staff can perform to best practicesDon’t just ask, but pull several kits and have users demonstrate how the kit is used and if it meets needs and best practices. Asking elicited one answer, demonstration of use provided very different responsesUse supply chain orders for volume use and type of lines used, but also consider direct order options. Go unit to unit and look for kits. Products can make their way into the institution without using supply chain.Worked with providers to come to an agreement on a limited number of CL kits to reduce variability and push toward best practiceLine cart – a JC NPSG Determine where carts should be locatedDetermine contents are standard for all cartsCreate standard work for maintaining supplies in cartManagement of non sterily placed linesDetermine what is considered a nonsterily placed line Create a process to communicate thisHCMC determined indicator would be a sticker placed on the line to change in 48 hours Consider other areas that may use CVC’s and the supplies needed. Ex: OR supplies – biopatch, tego, dressing; IR, etcMaintenanceEnsure dressing change kits have adequate supplies to meet best practiceDetermined to use a standard dressing change kit to allow staff best practice for line maintenanceUse supply chain orders for volume use and locations of product usedInterview nursing staff who perform dressing changesObserve dressing change practices by a variety of practice groups (ICU, floor, IV team)As a result of this process, HCMC found dressing kit did not have all the best tools, nor was there standard work for dressing changes and line maintenanceBecause of limitations by supplier to reconfigure dressing change kits to meet best practice, switched dressing from Sorbaview to Tegaderm after brief unit trial. Realized cost savings as in incidental effect in the dressing changeScrub the hubDetermine what product to use to prep the port prior to access – alcohol or CHGDetermine expectations for adequate hub prep. Contacted manufacturer of products and reviewed literature to determine length of time to scrub the hub. Best practice guidelines do not provide a time. Manufacturers only provide times to prep site for insertion and surgical procedures. Asked for manufacturer recommendations in writing and cited journal articles to determine HCMC would use a 10 second scrub and a 20 second dry time for hub prep.Dressing disruptionObservations by medical staff and nursing indicated not all CVC dressings were remaining intact, nor were the dressings being changed routinely when not in optimal condition. Reviewed literature and found recent evidence linking risk of infection related to number of unintended dressing disruptions. Incorporated into policy and EPIC documentation the practice to change CVC when 2 or more unintended disruptions occurredDressing options for patients without intact skin (eg Burn)Still to explore options. Not yet completeDaily assessment for needCome to an agreement of what is a daily assessment for needHow is this communicated to nursing staffHow is this documentedWhat are the downstream effects of the assessment – eg: order for removal, monitor, etcRemovalAgree to the timing of removal once the line is no longer medically necessaryWhat is the documentationInterviews revealed delays in removal related to time of day, availability IV team etc.Misperceptions of how to remove PICC’s and who was able to removeNeed to set expectations on unit and in policy of who can remove a central line and what type of central lineHow to manage documentation of patients discharged with central linesPolicyDevelop a hospital policy related to the best practices and unique practices and issues specific to facility. Ensure the support and agreement of the Steering Committee to promulgate the policy to peers. When to revisit/how to avoid the pendulum effectNeed to balance best practice and emphasize care of patient come first. Focus on prevention from leaders can push providers to avoiding the use of central lines and possible inappropriate use of peripheral lines. Daily CHG bathingDaily CHG bathing already established in the ICU’s. Need to find a way to expand this to the floors so that non-ICU patients with CVC’s get a daily bath with CHG. Need to make sure processes align with other initiatives (ex surgery pre-op, etc). TOOLS: PolicyInsertion checklistCHG daily bathingRounding checklistLine cart contentsEducation (DO)Baseline audit of best practicesUsing Best Practice and policy perform an audit of current activities. HCMC was able to use Biopatch reps, IP and IV staff to perform a 1 day point prevalence audit. Used this information to help determine education targetsNICU Reviewed NICU unit policies and discussed practices with NNP’s and physicians. Found variety of practices that were not optimal (ex how infant was draped, using sterile water to prep the skin instead of PI disinfectant with removal of PI after procedure, etc)Patient EducationJC NPSG requires the patient and/or their family to be educated to the risk of and prevention of CLABSI. HCMC decided to use the insertion checklist as the place to document education.Incorporated expectations into policy and topics to discussCreate an education plan that involves the caregiver as the agent of change and why the driving need for changeOnce plan is in place and best practices have been accepted by leadership. Involve key educators and staff. HCMC education team members:Project Team LeadersIPICU managerFloor managerNursing education departmentOffice of the Medical DirectorIV Team What should you educate?Determine who to educate and what is unique or special for the practice groupDetermine what each practice group should know and what should they know about others. Ie what should nursing know that is the responsibility of the provider. What should the provider know to expect from nursing. Use baseline audits to determine where gaps are for targeted educationWhy the change and why it is considered best practice. Give examples how implementing best practice leads to success Facility expectationsInsertion checklistWhere are supplies and what supplies should be used (ex line carts vs kits, dressing kits, etc)Maintenance expectations and return demonstrations of competencyAssessment for removalDocumentationDetermine frequency of educationAre there regulations that determine the frequency of education? HCMC is following Joint Commission requirements for those how are involved with CVC’supon hire, annually thereafter and when transfer of duties include CVC sResidentsAll residents must have successfully placed a simulated central line and Demonstrate competency per the Resident/Fellow Scope of PracticeDetermine how to educate (big bang/unit based/passive/active, etc)Select a method of education that fosters active learning and participation. HCMC required (as a condition of work to complete in a 1 month period of time)online facility made/facility specific videos to introduce concept and expectations nursing, residents, Staff MD’sIn addition nursing was required:Return demonstration and competency of dressing changeInteractive Q and A in the form of Jeopardy! Game for use and maintenance The HCW person was to be removed from the work schedule until education successful. Consider specialty educationWho can access implanted linesWho can remove central linesWho is trained to access dialysis lines Blood draws from dialysis lines for OR and ICU staff or those approved to draw bloodTOOLS:Biopatch point prevalence auditMD videoNursing videoLMS nursing PPTReNew materialWhat to educate the patient JC NPSGMeasurement (Study)InsertionChecklist observation tool – how to measure this use? How do you know if every non-tunneled, nonemergent line had 2 person insertion?What to do with insertions that don’t go well? Early on had some staff feel the checklist was unnecessary. The CMO was contacted and informed the staff member they would be suspended if they didn’t follow the policy and checklist. MaintenanceModify EPIC Dashboard. Added specific process measure data elements for nurse manager to monitorHow many days has the line been in placeWhen dressing change is due (so manager can go a do staff competency assessments)Nonsterily placed line indication (to monitor for timely removal)CHG bathing occuringBiopatch presentDaily assessment for needNumber of unintended dressing disruptions (to move to recommendation for new line)RemovalTime from order to removal? Device utilization?Why the line was removed – successful completion, complication…… Electronic Health Record (EHR)As measurements are being determined, include EHR staff to build the proper documentation structures for orders, insertion, and maintenance such that audits are easy for the front line managers and directorsDavita Put HCMC performance standards into contract and have unit report out compliance they monitor and report on a monthly basis: Hand hygiene compliance, biopatch presence, and intact transparent dressingsBarriers to successSurvey staff for possible knowledge deficits or barriers to successDenominator dataValidate the numerator and denominator dataTOOLS: IP Outcome reportsScreen shot of EPIC Radar Screen shot of denominatorsScreen shot of MD Note WriterDavita contract language for auditing requirements and expectation to HCMC policiesReporting requirement documentCommunication (ACT)OutcomesMonthly report emailed to leadership (Nursing managers, Medical Directors, CEO, CNO, senior nursing staff, quality, OMD, etc) Include rates and “Days Free” to post on each unit. Case reviews of all CLABSI occur within a week of determining the CLABSI. Include the inserting team if occurs within 7 days of insertion. Include residents attending.Rates posted on all unit visual management boardsPresent outcomes to Manager meetings, executive boardEducation ProgramsRelated where we are at, the goals and each person’s responsibility in the preventionReport staff compliance with attending education events to managers, CEO and OMDMeeting minutesSteering committee and work group minutes emailed to all team members weeklyProcess measuresAudit information given to all nursing and medical staff. Drilled to unit level. Hospital prioritiesHennepin Health System has 3 main priorities for 2014 (approved by Executive Leadership and County Board of Directors) One of the 3 main priorities included 3 Infection Prevention initiatives: CLABSI, CAUTI and SSI TOOLS: Nursing Huddle message examplesManager huddle presentationsMonthly report exampleBoard presentationsSustain (ACT)Followup with areas as differences come to lightEx Tegos in the OR? Or supplies? How to know if a person is competent to insert a lineHow do you know a resident is competent to insert?Continue competency Per JC Staff will periodically be assessed for knowledge of adherence to insertion and maintenance best practices. Determine what should staff be held accountable toWho performs the competency assessmentWhat will be remediation toolsMeasurement frequency of process measures and outcomesDetermine who sees these process measures and outcomes. Who has influence to reinforce and accountable for holding staff to performing audits, etcEliminate barriers to successCase reviews of infections to determine if best practices are still in place and/or what prevented practicing best practices. See #1 in sustainElse?Develop standard work for CLABSI Case ReviewWhat elements should be reviewed each time and who should be present ................
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